Healthcare Provider Details

I. General information

NPI: 1548551278
Provider Name (Legal Business Name): JEROME YELDER SR. PHD PSYD MBA MS MP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date: 05/10/2020
Reactivation Date: 07/08/2020

III. Provider practice location address

1101 BELLEVIEW ST STE 104
COLUMBIA SC
29201-1863
US

IV. Provider business mailing address

1101 BELLEVIEW ST STE 104
COLUMBIA SC
29201-1863
US

V. Phone/Fax

Practice location:
  • Phone: 803-937-1623
  • Fax: 803-937-1623
Mailing address:
  • Phone: 803-937-1623
  • Fax: 803-937-1623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number45428
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number61388
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number573768
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number159AMP
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number73276
License Number StateSC
# 6
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number73276
License Number StateSC
# 7
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number5768
License Number StateSC
# 8
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number159AMP
License Number StateSC
# 9
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number159AMP
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: