Provider Demographics
NPI:1508557943
Name:WADE, JESSICA (MSE)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:MSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 BLACKLAND RD
Mailing Address - Street 2:
Mailing Address - City:OIL TROUGH
Mailing Address - State:AR
Mailing Address - Zip Code:72564-9750
Mailing Address - Country:US
Mailing Address - Phone:870-799-9013
Mailing Address - Fax:
Practice Address - Street 1:221 LINDLEY LN
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-4954
Practice Address - Country:US
Practice Address - Phone:870-523-2124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist