Provider Demographics
NPI:1790526358
Name:WADE, JACQUELINE SHERRY (BMHCC, IINHCC, BHCC,)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:SHERRY
Last Name:WADE
Suffix:
Gender:F
Credentials:BMHCC, IINHCC, BHCC,
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:SHERRY
Other - Last Name:BARRETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BMHCC, IINHCC, BHCC
Mailing Address - Street 1:5508 S LEWIS AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-7105
Mailing Address - Country:US
Mailing Address - Phone:918-985-1129
Mailing Address - Fax:
Practice Address - Street 1:5508 S LEWIS AVE STE 200
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-7105
Practice Address - Country:US
Practice Address - Phone:918-985-1129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3512610284133N00000X, 171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionist