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Individual
JEREMY WALLACE JACK
Active
Individual
JEREMY WALLACE JACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LCPC
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
31177
MT
171M00000X
Case Manager/Care Coordinator
—
—
172V00000X
Community Health Worker
—
—
Other
Enumeration date
06/02/2011
Last updated
08/31/2020
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