Provider Demographics
NPI:1386447605
Name:EVENSTAD, JADE GISELE
Entity type:Individual
Prefix:
First Name:JADE
Middle Name:GISELE
Last Name:EVENSTAD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-3549
Mailing Address - Country:US
Mailing Address - Phone:570-808-8780
Mailing Address - Fax:570-808-8785
Practice Address - Street 1:166 HANOVER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-3549
Practice Address - Country:US
Practice Address - Phone:570-808-8780
Practice Address - Fax:570-808-8785
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program