Provider Demographics
NPI:1720778251
Name:WADE, JAMIE D
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:D
Last Name:WADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 PR 25162
Mailing Address - Street 2:
Mailing Address - City:SOUTH TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-2074
Mailing Address - Country:US
Mailing Address - Phone:903-244-6184
Mailing Address - Fax:
Practice Address - Street 1:86 PR 25162
Practice Address - Street 2:
Practice Address - City:SOUTH TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-2074
Practice Address - Country:US
Practice Address - Phone:903-244-6184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX172A00000X, 171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No172A00000XOther Service ProvidersDriver