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General NPI Number Information
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NPI Number | 1538494489
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Entity Type | Individual
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Provider Name | JEREMY PAUL WADE FNP, ENP, PMHNP
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Gender | Male
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Dates
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Enumeration Date | 10/09/2009
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Last Update Date | 06/18/2024
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Provider Practice Location Address
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Address Line | 1047 S WELLS ST
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City | MERIDIAN
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State | ID
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Zip | 83642-7997
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Country | US
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Telephone | 601-451-4333
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Fax | 888-317-1077
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Provider Business Mailing Address
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Address Line | 4780 I 55 N, SUITE 116 PMB 989333
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City | JACKSON
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State | MS
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Zip | 39211-6067
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Country | US
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Telephone | 601-451-4333
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Fax | 888-317-1077
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 10017010
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 862789
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License Number State | MS
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | CS72647
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License Number State | ID
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Taxonomy #4
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 10017010
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License Number State | OR
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Taxonomy #5
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 77657
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License Number State | ID
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Taxonomy #6
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 77657
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License Number State | ID
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Taxonomy #7
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | CS72647
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License Number State | ID
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Taxonomy #8
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 862789
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License Number State | MS
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Taxonomy #9
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 10017010
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License Number State | OR
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Taxonomy #10
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 862789
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License Number State | MS
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