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General NPI Number Information
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NPI Number | 1457203176
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Entity Type | Individual
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Provider Name | ALEXANDER JEREMY WALLACE MSW
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Gender | Male
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Dates
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Enumeration Date | 02/13/2026
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Last Update Date | 02/13/2026
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Provider Practice Location Address
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Address Line | 1708 BANYAN CT
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City | CERES
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State | CA
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Zip | 95307-1907
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Country | US
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Telephone | 209-531-2088
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Fax |
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Provider Business Mailing Address
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Address Line | 701 N TUXEDO AVE
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City | STOCKTON
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State | CA
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Zip | 95204-5129
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | ASW136556
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License Number State | CA
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