Provider Demographics
NPI:1114363132
Name:WATERS DAVIS, JESSICA SUSAN (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUSAN
Last Name:WATERS DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 WATERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-9078
Mailing Address - Country:US
Mailing Address - Phone:984-215-2095
Mailing Address - Fax:
Practice Address - Street 1:322 MAIN ST
Practice Address - Street 2:
Practice Address - City:PROSPECT HILL
Practice Address - State:NC
Practice Address - Zip Code:27314-9438
Practice Address - Country:US
Practice Address - Phone:336-562-3311
Practice Address - Fax:336-562-4444
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-01549207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist