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NPI Code Detail

MEDICARE: TYRA WADE

MEDICARE: TYRA WADE
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
1101YM0800XMental Health Counselor
2171M00000XCase Manager/Care Coordinator

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1477735769
Entity Type Code : Individual
Provider Name (Legal Business Name) : TYRA WADE
Provider Business Mailing Address
First Line : 4780 I 55 N STE 105
Second Line :
City : JACKSON
State : MS
Zip : 39211-5542
Country : US
Telephone Number : 601-956-4816
Fax Number : 601-956-4817
Provider Business Practice Location Address
First Line : 4780 I 55 N STE 105
Second Line :
City : JACKSON
State : MS
Zip : 39211-5542
Country : US
Telephone Number : 601-956-4816
Fax Number : 601-956-4817
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/29/2007
Last Update Date : 03/10/2022

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1548697121 — SHIRLEY JONES MSW, CMHT
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Directions to “ TYRA WADE ” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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