JONATHAN W WALLACE Medical Doctor License verification

Business Entity

NOT RENEWED

License Type

Medical Doctor

Description

LICENSED PHYSICIAN CONTROLLED SUBSTANCE

License Number

33*****15

License Status

NOT RENEWED

Business

First Name

JONATHAN

Middle

Last Name

WALLACE

Business Name

JONATHAN W WALLACE

Original Issue Date

04/07/2003

Effective Date

04/07/2003

Expiration Date

07/31/2005

City

ELK GROVE VILLAGE

State

Zip

60007

County

COOK

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

04/05/2020