Healthcare Provider Details

I. General information

NPI: 1164572384
Provider Name (Legal Business Name): JAMI L WADE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 AVENUE B SE
WINTER HAVEN FL
33880-3037
US

IV. Provider business mailing address

1065 CLEARPOINTE WAY
LAKELAND FL
33813-5618
US

V. Phone/Fax

Practice location:
  • Phone: 863-294-1429
  • Fax: 863-298-0299
Mailing address:
  • Phone: 863-294-1429
  • Fax: 863-298-0299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA8321
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: