| Doctor Name: | JERMAINE WALLACE |
| NPI Number: | 1003124025 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 223 E Main St Suite 300 Rock Hill, SC - 297304571 |
| Business Phone Number: | 8033289600 |
| Business Fax Number: | 8033287141 |
| Mailing Address: | 250 Piedmont Blvd, ROCK HILL |
| State: | SC |
| Postal Code: | 297321835 |
| Phone Number: | 8033289600 |
| Fax Number: | 8033287141 |
| NPI Enumeration Date: | 09/24/2010 |
| NPI Last Update Date: | 09/24/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |