Provider Demographics
NPI:1821573387
Name:WALLACE, JERRYD (LPC)
Entity Type:Individual
Prefix:
First Name:JERRYD
Middle Name:
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2020
Mailing Address - Street 2:
Mailing Address - City:VAN ALSTYNE
Mailing Address - State:TX
Mailing Address - Zip Code:75495-2020
Mailing Address - Country:US
Mailing Address - Phone:469-667-3515
Mailing Address - Fax:
Practice Address - Street 1:162 N. DALLAS AVE
Practice Address - Street 2:
Practice Address - City:VAN ALSTYNE
Practice Address - State:TX
Practice Address - Zip Code:75495-7549
Practice Address - Country:US
Practice Address - Phone:469-667-3515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX77418101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional