DR. JACOB HENRY WALLACE (MD) – Obstetrics & Gynecology Physician, NPI 1124604061
Obstetrics & Gynecology Physician
Main info
Doctor Profile
Profile Insights
NPPES metrics only — not quality of care.
931 OBSTETRICS/GYNECOLOGY in MO
Provider Addresses for DR. JACOB HENRY WALLACE (MD)
3990 BOWEN ST
SAINT LOUIS, MO 631163145
Phone: (989) 751-6079
Type: Mailing
401 HOLLY HILLS AVE
SAINT LOUIS, MO 631112410
Phone: (314) 353-5190
Fax: (314) 353-7631
Type: Location
904 LAMBETH CIR APT 208
DURHAM, NC 277054587
Phone: (989) 751-6079
Type: Mailing
4352 Manchester Ave
Saint Louis, MO 631102138
Phone: (314) 531-5444
Fax: (314) 531-0063
Type: Location
6420 CLAYTON RD
SAINT LOUIS, MO 631171811
Phone: (314) 768-8000
Type: Location
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
No Open Payments data available for this provider.
This can happen when there are no reportable CMS Open Payments records.
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2025-07-16
PECOS data refreshed: 2026-06-15
Medicare revalidation (CMS due date list)
Due date not assigned yet
CMS is tracking this Medicare enrollment for revalidation, but has not published a due date.
Enrollment records
1
Earliest due date
Not assigned (TBD)
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| I20250716000325 | I | Obstetrics/Gynecology | MO | TBD |
What to do next
- No action required while the due date shows TBD.
- Check the CMS Revalidation Lookup Tool periodically — CMS updates the list about every 60 days.
- Do not submit a revalidation application in PECOS until CMS publishes a concrete due date.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 63116)
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Group practice members
| Name | Specialty | State |
|---|---|---|
| C H I R O P R A C T I C | MO | |
| - | MO | |
| Family Practice | MO | |
| Clinical Social Worker | MO | |
| - | MO | |
| O P T O M E T R Y | MO | |
| Internal Medicine | MO | |
| Nurse Practitioner | MO | |
| Nurse Practitioner | MO | |
| Internal Medicine | MO |
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