Provider Demographics
NPI:1699760934
Name:WALLACE, JENNIFER L (M D)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:WALLACE
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7720 JONES MALTSBERGER
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216
Mailing Address - Country:US
Mailing Address - Phone:210-822-2004
Mailing Address - Fax:210-822-2215
Practice Address - Street 1:7720 JONES MALTSBERGER
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216
Practice Address - Country:US
Practice Address - Phone:210-822-2004
Practice Address - Fax:210-822-2215
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9277207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117537404Medicaid
TX117537405Medicaid
TX135685902Medicaid
TX8DL467OtherBCBSTX
TX117537405Medicaid
TXB109659Medicare PIN
TX117537404Medicaid
TXB161317Medicare PIN