Provider Demographics
NPI:1346959897
Name:WATERS, JENNIE
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GENERAL DELIVERY
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-9999
Mailing Address - Country:US
Mailing Address - Phone:701-989-1957
Mailing Address - Fax:
Practice Address - Street 1:3720 CENTENNIAL RD SPC 74
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-8001
Practice Address - Country:US
Practice Address - Phone:701-989-1957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant