Healthcare Provider Details

I. General information

NPI: 1538494489
Provider Name (Legal Business Name): JEREMY PAUL WADE FNP, ENP, PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2009
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1047 S WELLS ST
MERIDIAN ID
83642-7997
US

IV. Provider business mailing address

4780 I 55 N, SUITE 116 PMB 989333
JACKSON MS
39211-6067
US

V. Phone/Fax

Practice location:
  • Phone: 601-451-4333
  • Fax: 888-317-1077
Mailing address:
  • Phone: 601-451-4333
  • Fax: 888-317-1077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number10017010
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number862789
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCS72647
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10017010
License Number StateOR
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number77657
License Number StateID
# 6
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number77657
License Number StateID
# 7
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCS72647
License Number StateID
# 8
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number862789
License Number StateMS
# 9
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10017010
License Number StateOR
# 10
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number862789
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: