Provider Demographics
NPI:1538494489
Name:WADE, JEREMY PAUL (FNP, ENP, PMHNP)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:PAUL
Last Name:WADE
Suffix:
Gender:M
Credentials:FNP, ENP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 WALTER LOTT RD
Mailing Address - Street 2:
Mailing Address - City:SEMINARY
Mailing Address - State:MS
Mailing Address - Zip Code:39479-4414
Mailing Address - Country:US
Mailing Address - Phone:601-520-1756
Mailing Address - Fax:888-317-1077
Practice Address - Street 1:136 WALTER LOTT RD
Practice Address - Street 2:
Practice Address - City:SEMINARY
Practice Address - State:MS
Practice Address - Zip Code:39479-4414
Practice Address - Country:US
Practice Address - Phone:601-451-4333
Practice Address - Fax:888-317-1077
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-09
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10017010163W00000X, 363LF0000X, 363LP0808X
IDCS72647363LF0000X, 363LP0808X
MS862789363LP0808X, 163W00000X, 363LF0000X
ID77657363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00534527Medicaid