Provider Demographics
NPI:1093064685
Name:WOLVERTON-WADE, JENNIFER LISA (RN, CWCN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LISA
Last Name:WOLVERTON-WADE
Suffix:
Gender:F
Credentials:RN, CWCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 KEY HONEY LANE
Mailing Address - Street 2:
Mailing Address - City:TAVERNIER
Mailing Address - State:FL
Mailing Address - Zip Code:33070
Mailing Address - Country:US
Mailing Address - Phone:860-328-0013
Mailing Address - Fax:
Practice Address - Street 1:3000 41ST ST
Practice Address - Street 2:
Practice Address - City:MARATHON
Practice Address - State:FL
Practice Address - Zip Code:33050
Practice Address - Country:US
Practice Address - Phone:305-434-7660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9333023163WA0400X, 163WP0809X, 163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No163WW0000XNursing Service ProvidersRegistered NurseWound Care