Provider Demographics
NPI:1245103431
Name:WADE, DONNA L
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:L
Last Name:WADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 LANDMARK LOOP
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2133
Mailing Address - Country:US
Mailing Address - Phone:731-394-2886
Mailing Address - Fax:
Practice Address - Street 1:620 OLD HICKORY BLVD STE 410D
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2904
Practice Address - Country:US
Practice Address - Phone:731-394-2886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-25
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10000000389623104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness