| Doctor Name: | JENNIFER LEE WALLACE |
| NPI Number: | 1679983449 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | MSW, LSW |
| License Number: | SW126587 |
| Business Practice Address: | 1 W Main St Fleetwood, PA - 195221323 |
| Business Phone Number: | 6109440445 |
| Business Fax Number: | 6109448834 |
| Mailing Address: | 555 Ridge Rd, ORWIGSBURG |
| State: | PA |
| Postal Code: | 179612217 |
| Phone Number: | 6109607658 |
| Fax Number: | |
| NPI Enumeration Date: | 05/02/2014 |
| NPI Last Update Date: | 05/02/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | SW126587 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | PA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |