Healthcare Provider Details

I. General information

NPI: 1053736231
Provider Name (Legal Business Name): JENNIFER KATHERINE WADE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2014
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28105 THREE NOTCH RD # 1C
MECHANICSVILLE MD
20659-3235
US

IV. Provider business mailing address

1512 ABBEY LN
HUNTINGTOWN MD
20639-2310
US

V. Phone/Fax

Practice location:
  • Phone: 301-290-1510
  • Fax: 301-290-1574
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR194448
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: