MEDICARE: JENELLE WADE M.S., BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-13-14936	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1-13-14936	OTHER	CA	BCBA

General Provider Information

NPI Number	:	1134530538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENELLE WADE M.S., BCBA

Provider Business Mailing Address
First Line	:	3650 MT DIABLO BLVD STE 107
Second Line	:
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-3780
Country	:	US
Telephone Number	:	734-546-5352
Fax Number	:

Provider Business Practice Location Address
First Line	:	3650 MT DIABLO BLVD STE 107
Second Line	:
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-3780
Country	:	US
Telephone Number	:	510-665-9700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2014
Last Update Date	:	12/21/2018

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