Provider Demographics
NPI:1336595172
Name:WADE, JENNIFER (MED,CCC/SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:MED,CCC/SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:BARRON
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED,CCC/SLP
Mailing Address - Street 1:336 RAMBLIN RD
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31643-5809
Mailing Address - Country:US
Mailing Address - Phone:229-506-1362
Mailing Address - Fax:
Practice Address - Street 1:336 RAMBLIN RD
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:GA
Practice Address - Zip Code:31643-5809
Practice Address - Country:US
Practice Address - Phone:229-506-1362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005982235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist