Provider Demographics
NPI:1831775006
Name:WADE, JESSICA WALLER
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:WALLER
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 1:317 DARTMOUTH DRIVE, BLDG 4, UNIT 3
Mailing Address - Street 2:
Mailing Address - City:MARSHALLS CREEK
Mailing Address - State:PA
Mailing Address - Zip Code:18335
Mailing Address - Country:US
Mailing Address - Phone:570-730-4211
Mailing Address - Fax:
Practice Address - Street 1:317 DARTMOUTH DRIVE, BLDG 4, UNIT 3
Practice Address - Street 2:
Practice Address - City:MARSHALLS CREEK
Practice Address - State:PA
Practice Address - Zip Code:18335
Practice Address - Country:US
Practice Address - Phone:570-730-4211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW134964104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker