Provider Demographics
NPI:1396039897
Name:JACK, JEREMY WALLACE (LCPC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:WALLACE
Last Name:JACK
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 MAIN ST # B-C
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59105-1712
Mailing Address - Country:US
Mailing Address - Phone:406-606-9552
Mailing Address - Fax:
Practice Address - Street 1:1411 MAIN ST STE B-C
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59105-1712
Practice Address - Country:US
Practice Address - Phone:406-606-9552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X
MT31177101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker