Provider Demographics
NPI:1245760529
Name:WADE, JEREMY A
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:A
Last Name:WADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1213
Mailing Address - Street 2:
Mailing Address - City:HILLIARD
Mailing Address - State:OH
Mailing Address - Zip Code:43026-6213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W BRIDGE ST STE B
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-1141
Practice Address - Country:US
Practice Address - Phone:614-547-9233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X
OHC.1000486101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health