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General NPI Number Information
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NPI Number | 1790526358
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Entity Type | Individual
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Provider Name | JACQUELINE SHERRY WADE BMHCC, IINHCC, BHCC,
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Gender | Female
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Dates
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Enumeration Date | 06/05/2024
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Last Update Date | 06/05/2024
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Provider Practice Location Address
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Address Line | 5508 S LEWIS AVE STE 200
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City | TULSA
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State | OK
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Zip | 74105-7105
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Country | US
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Telephone | 918-985-1129
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Fax |
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Provider Business Mailing Address
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Address Line | 5508 S LEWIS AVE STE 200
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City | TULSA
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State | OK
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Zip | 74105-7105
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Country | US
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Telephone | 918-985-1129
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Fax |
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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 | 133N00000X
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Taxonomy Name | Nutritionist
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License Number | 3512610284
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 171400000X
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Taxonomy Name | Health & Wellness Coach
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License Number | 3512610284
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License Number State | OK
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