Provider Demographics
NPI:1801243605
Name:WANGER, JADE (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:
Last Name:WANGER
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 THINGVALLA AVE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-3668
Mailing Address - Country:US
Mailing Address - Phone:608-220-0306
Mailing Address - Fax:
Practice Address - Street 1:282 FARMERS ROW
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:MA
Practice Address - Zip Code:01450-1848
Practice Address - Country:US
Practice Address - Phone:978-448-3363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-21
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0020772255A2300X
MA35142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer