Provider Demographics
NPI:1134477490
Name:WADE, JENNIFER MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARIE
Last Name:WADE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 VILLA JUNO DR S
Mailing Address - Street 2:
Mailing Address - City:JUNO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33408-2402
Mailing Address - Country:US
Mailing Address - Phone:908-565-1079
Mailing Address - Fax:
Practice Address - Street 1:10301 HAGEN RANCH RD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3724
Practice Address - Country:US
Practice Address - Phone:954-581-3533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115997363A00000X
NY015862363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant