Provider Demographics
NPI:1114326691
Name:WATERS, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:WATERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4265 MUGGLE LN
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-5200
Mailing Address - Country:US
Mailing Address - Phone:406-830-0680
Mailing Address - Fax:
Practice Address - Street 1:2809 GREAT NORTHERN LOOP
Practice Address - Street 2:#200
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1749
Practice Address - Country:US
Practice Address - Phone:406-830-0680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician