Provider Demographics
NPI:1326384843
Name:WADE, JENNIFER R (MED, BCBA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:WADE
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 TALL HICKORY DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4805
Mailing Address - Country:US
Mailing Address - Phone:804-539-9987
Mailing Address - Fax:
Practice Address - Street 1:4501 TALL HICKORY DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4805
Practice Address - Country:US
Practice Address - Phone:804-539-9987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000139103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst