Provider Demographics
NPI:1639968365
Name:WAGELEY, JADE SHIKIKO
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:SHIKIKO
Last Name:WAGELEY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 CRUCES LOOP
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-0015
Mailing Address - Country:US
Mailing Address - Phone:505-378-7534
Mailing Address - Fax:
Practice Address - Street 1:51 CRUCES LOOP
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-0015
Practice Address - Country:US
Practice Address - Phone:505-378-7534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst