| Doctor Name: | MR. JOHN JASON WALLACE |
| NPI Number: | 1063652097 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LCSW |
| License Number: | CW015384 |
| Business Practice Address: | 1111 E End Blvd Wilkes Barre, PA - 187110030 |
| Business Phone Number: | 5708243521 |
| Business Fax Number: | |
| Mailing Address: | 1111 E End Blvd, WILKES BARRE |
| State: | PA |
| Postal Code: | 187110030 |
| Phone Number: | 5708243521 |
| Fax Number: | |
| NPI Enumeration Date: | 03/04/2009 |
| NPI Last Update Date: | 03/04/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | CW015384 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | PA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |