Individual
JERRON WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LMSW
Contact information
Practice address
912 1ST ST NW, ALBUQUERQUE, NM 87102-2355
(505) 224-9777
Mailing address
912 1ST ST NW, ALBUQUERQUE, NM 87102-2355
(505) 224-9777
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
X-09336
NM
Other
Enumeration date
09/30/2015
Last updated
01/19/2017
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