Provider Demographics
NPI:1336698067
Name:VERGE, JADE NICOLE (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:JADE
Middle Name:NICOLE
Last Name:VERGE
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 OLD GREENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-6411
Mailing Address - Country:US
Mailing Address - Phone:479-459-0636
Mailing Address - Fax:
Practice Address - Street 1:105 E RAY FINE BLVD STE L
Practice Address - Street 2:
Practice Address - City:ROLAND
Practice Address - State:OK
Practice Address - Zip Code:74954-5331
Practice Address - Country:US
Practice Address - Phone:918-675-0075
Practice Address - Fax:918-675-0801
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR2964225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR217131721Medicaid