JACOB WALLACE (A.P.R.N) – Family Nurse Practitioner, NPI 1639915911
Family Nurse Practitioner
Main info
Doctor Profile
Profile Insights
NPPES metrics only — not quality of care.
2,655 NURSE PRACTITIONER in UT
Provider Addresses for JACOB WALLACE (A.P.R.N)
PO BOX 912042
ST GEORGE, UT 847912042
Phone: (435) 215-0230
Fax: (435) 986-7092
Type: Mailing
630 E 1400 N STE 135
LOGAN, UT 843412549
Phone: (435) 787-8146
Fax: (435) 787-8149
Type: Location
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
CMS reports 9 Open Payments records for all available years, with a total value of $497.
Total Amount is formed as General ($497) + Research ($0) + Ownership ($0) = $497.
Last reported payment date: 2024-12-16 • Largest payer in this snapshot: Medtronic, Inc. ($479).
Total Amount
$497
General + Research + Ownership
Payments
9
Total payment records
General Amount
$497
General payments
Research Amount
$0
Research funding
Ownership Amount
$0
Ownership interests
Ownership Count
0
Ownership records
Last Payment Date
2024-12-16
Latest reported date
Top Companies
Largest payers in this snapshot
| Company | Amount |
|---|---|
| Medtronic, Inc. | $479 |
| Collegium Pharmaceutical, Inc. | $18 |
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: 2024-08-27
PECOS data refreshed: 2026-05-27
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 |
|---|---|---|---|---|
| I20240827003897 | I | Nurse Practitioner | UT | 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 84791)
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Group practice members
| Name | Specialty | State |
|---|---|---|
| Nurse Practitioner | UT | |
| Physical Therapist In Private Practice | UT | |
| Physician Assistant | MD | |
| N E U R O L O G Y | WI | |
| Nurse Practitioner | UT | |
| Nurse Practitioner | UT | |
| Nurse Practitioner | UT | |
| - | UT | |
| R H E U M A T O L O G Y | UT | |
| Physician Assistant | UT |
Reviews
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