Provider Demographics
NPI:1386113900
Name:WADE, JONATHAN MARVIN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MARVIN
Last Name:WADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7540 HIGHWAY 64 W
Mailing Address - Street 2:
Mailing Address - City:BRASSTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28902-8079
Mailing Address - Country:US
Mailing Address - Phone:828-837-5335
Mailing Address - Fax:
Practice Address - Street 1:7540 HIGHWAY 64 W
Practice Address - Street 2:
Practice Address - City:BRASSTOWN
Practice Address - State:NC
Practice Address - Zip Code:28902-8079
Practice Address - Country:US
Practice Address - Phone:828-837-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23249101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC23249Medicaid