Healthcare Provider Details

I. General information

NPI: 1255798989
Provider Name (Legal Business Name): JENNIFER WADE O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2016
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 S 52ND ST
ROGERS AR
72758-8602
US

IV. Provider business mailing address

3232 N NORTHHILLS BLVD
FAYETTEVILLE AR
72703-4005
US

V. Phone/Fax

Practice location:
  • Phone: 479-587-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License NumberOTR2857
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number06596
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number12947
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: