Individual
MR. JEREMY PAUL WADE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
FNP, ENP, PMHNP
Contact information
Practice address
1047 S WELLS ST, MERIDIAN, ID 83642-7997
(601) 451-4333
(888) 317-1077
Mailing address
4780 I 55 N, SUITE 116, PMB 989333, JACKSON, MS 39211-6067
(601) 451-4333
(888) 317-1077
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
10017010
OR
163W00000X
Registered Nurse
862789
MS
363LF0000X
Family Nurse Practitioner
10017010
OR
363LF0000X
Family Nurse Practitioner
77657
ID
363LF0000X
Family Nurse Practitioner
Primary
862789
MS
363LF0000X
Family Nurse Practitioner
CS72647
ID
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
10017010
OR
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
77657
ID
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
862789
MS
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
CS72647
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00534527
—
MS
05
—
500830485
—
OR
Enumeration date
10/09/2009
Last updated
06/18/2024
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