Provider Demographics
NPI:1548551278
Name:YELDER, JEROME SR (PHD PSYD MBA MS MP)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:
Last Name:YELDER
Suffix:SR
Gender:M
Credentials:PHD PSYD MBA MS MP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 BELLEVIEW ST STE 104
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-1863
Mailing Address - Country:US
Mailing Address - Phone:803-937-1623
Mailing Address - Fax:803-937-1623
Practice Address - Street 1:1101 BELLEVIEW ST STE 104
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-1863
Practice Address - Country:US
Practice Address - Phone:803-937-1623
Practice Address - Fax:803-937-1623
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2020-07-08
Deactivation Date:2020-05-10
Deactivation Code:
Reactivation Date:2020-07-08
Provider Licenses
StateLicense IDTaxonomies
SC45428101YA0400X
SC61388101YP1600X
SC573768103G00000X
SC159AMP171000000X, 208VP0014X, 103TP0016X
SC73276171W00000X, 174H00000X, 251S00000X, 252Y00000X, 251B00000X, 251E00000X, 251K00000X, 251V00000X
SC57681835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No171000000XOther Service ProvidersMilitary Health Care Provider
No171W00000XOther Service ProvidersContractor
No174H00000XOther Service ProvidersHealth Educator
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No251K00000XAgenciesPublic Health or Welfare
No251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP7839Medicaid
SC273614612Medicaid