Provider Demographics
NPI:1023483716
Name:WADE, JENNIFER (LAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7238 W EVERELL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-1933
Mailing Address - Country:US
Mailing Address - Phone:773-406-2091
Mailing Address - Fax:
Practice Address - Street 1:3817 N PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-3141
Practice Address - Country:US
Practice Address - Phone:773-234-0714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-06
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000974171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist