Provider Demographics
NPI:1073863908
Name:WATERS, JEANNETTE L (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:L
Last Name:WATERS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2148 SAGECREST LOOP NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-2856
Mailing Address - Country:US
Mailing Address - Phone:505-463-8195
Mailing Address - Fax:
Practice Address - Street 1:2148 SAGECREST LOOP NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-2856
Practice Address - Country:US
Practice Address - Phone:505-463-8195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM289235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM289OtherNEW MEXICO STATE LICENSURE FOR SPEECH PATHOLOGY
NM01030680OtherAMERICAN SPEECH, LANGUAGE, HEARING CERTIFICATION NUMBER