Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | ||
N | 101YM0800X | Mental Health Counselor | ||
N | 101YP1600X | Pastoral Counselor |
NPI | 1366795890 |
---|---|
Provider Name | Mr. Jonathan Lewis Wade SR. |
First Address | Lindenwold, NJ 08021-6878 |
Second Address | Brookhaven, PA 19015-1228 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/10/2012 |
Last Update Date | 22/10/2012 |