Healthcare Provider Details

I. General information

NPI: 1629856190
Provider Name (Legal Business Name): JACOB WADE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 01/01/2025
Certification Date: 01/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 GREENBUSH ST
LAFAYETTE IN
47904-2479
US

IV. Provider business mailing address

3907 ALEX CT
LAFAYETTE IN
47905-7746
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax: 765-447-9749
Mailing address:
  • Phone: 765-250-7779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number28259521A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71015663A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: