Provider Demographics
NPI:1073644837
Name:WATSON, JEREMY BEAU (MA, MFTI)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:BEAU
Last Name:WATSON
Suffix:
Gender:M
Credentials:MA, MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22111 CALVERT ST APT 218
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-3570
Mailing Address - Country:US
Mailing Address - Phone:818-497-2937
Mailing Address - Fax:
Practice Address - Street 1:15317 RAYEN ST
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-5117
Practice Address - Country:US
Practice Address - Phone:818-892-3423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50579106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist