Provider Demographics
NPI:1114282589
Name:WATTERS, JAYNE ANN (CO)
Entity Type:Individual
Prefix:MRS
First Name:JAYNE
Middle Name:ANN
Last Name:WATTERS
Suffix:
Gender:F
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22215 TUPPER ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:WINFIELD
Mailing Address - State:KS
Mailing Address - Zip Code:67156-7326
Mailing Address - Country:US
Mailing Address - Phone:620-705-1106
Mailing Address - Fax:
Practice Address - Street 1:22215 TUPPER ST
Practice Address - Street 2:SUITE B
Practice Address - City:WINFIELD
Practice Address - State:KS
Practice Address - Zip Code:67156-7326
Practice Address - Country:US
Practice Address - Phone:620-705-1106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSCO2702174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSCO2702OtherCERTIFIED ORTHOTIST