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NPI Code Detail

MEDICARE: JEREMY WALLACE JACK LCPC

MEDICARE: JEREMY WALLACE JACK LCPC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1171M00000XCase Manager/Care Coordinator
2172V00000XCommunity Health Worker
3101Y00000XCounselor31177MT

General Provider Information

NPI Number : 1396039897
Entity Type Code : Individual
Provider Name (Legal Business Name) : JEREMY WALLACE JACK LCPC
Provider Business Mailing Address
First Line : 1411 MAIN ST # B-C
Second Line :
City : BILLINGS
State : MT
Zip : 59105-1712
Country : US
Telephone Number : 406-606-9552
Fax Number :
Provider Business Practice Location Address
First Line : 1411 MAIN ST STE B-C
Second Line :
City : BILLINGS
State : MT
Zip : 59105-1712
Country : US
Telephone Number : 406-606-9552
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/02/2011
Last Update Date : 08/31/2020

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