National Provider Identifier
Jackie Wallace, CRPA
Jackie Wallace, CRPA is listed in the NPPES registry with a primary specialty of Peer Specialist in Rochester, NY and a listed phone number of (585) 694-1307.
Profile Overview
- NPI
- 1609751080
- Provider Type
- Individual
- Primary Specialty
- Peer Specialist
- Enumeration Date
- August 06, 2025
- Last Updated
- August 06, 2025
Practice Location
- 2069 Hudson Ave.
- D
- Rochester, NY 14617
Phone: (585) 694-1307
Mailing Address
- 150 Mt.Hope Ave
- Rochester, NY 14620
Specialties
- Peer Specialist (175T00000X)
Full Record
- NPI
- 1609751080
- Entity Type
- Individual
- Last Name
- Wallace
- First Name
- Jackie
- Credential
- CRPA
- Mailing Street Address
- 150 Mt.Hope Ave
- Mailing City
- Rochester
- Mailing State
- NY
- Mailing ZIP Code
- 14620
- Mailing Country
- US
- Mailing Phone
- (585) 706-7983
- Practice Street Address
- 2069 Hudson Ave.
- Practice Address Line 2
- D
- Practice City
- Rochester
- Practice State
- NY
- Practice ZIP Code
- 14617
- Practice Country
- US
- Practice Phone
- (585) 694-1307
- Enumeration Date
- August 06, 2025
- Last Updated
- August 06, 2025
- Sex
- Male
- Sole Proprietor
- Yes
- Taxonomy Group 1
- 193400000X Single Specialty Group
- Certification Date
- August 01, 2025
- updated_by_file
- npidata_pfile_20050523-20260308.csv
- Taxonomies
- Peer Specialist (175T00000X)