Provider Demographics
NPI:1376299032
Name:JESSE WADE THERAPY INC.
Entity Type:Organization
Organization Name:JESSE WADE THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:916-616-4504
Mailing Address - Street 1:2001 N ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811-4237
Mailing Address - Country:US
Mailing Address - Phone:916-616-4505
Mailing Address - Fax:
Practice Address - Street 1:2001 N ST STE 100
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-4237
Practice Address - Country:US
Practice Address - Phone:916-616-4505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1194159897OtherOTHER AGENCY