Provider Demographics
NPI:1104181957
Name:WATSON, JESSICA COOK (DMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:COOK
Last Name:WATSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 LULLWATER RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-3180
Mailing Address - Country:US
Mailing Address - Phone:229-883-1306
Mailing Address - Fax:229-883-1357
Practice Address - Street 1:2305 LULLWATER RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-3180
Practice Address - Country:US
Practice Address - Phone:229-883-1306
Practice Address - Fax:229-883-1357
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0144151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice