Healthcare Provider Details

I. General information

NPI: 1376299032
Provider Name (Legal Business Name): JESSE WADE THERAPY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 N ST STE 100
SACRAMENTO CA
95811-4237
US

IV. Provider business mailing address

2001 N ST STE 100
SACRAMENTO CA
95811-4237
US

V. Phone/Fax

Practice location:
  • Phone: 916-616-4505
  • Fax:
Mailing address:
  • Phone: 916-616-4505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSE WADE
Title or Position: PRESIDENT
Credential: PSYD
Phone: 916-616-4504