Provider Demographics
NPI:1407152358
Name:WATERS, JACK B (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:B
Last Name:WATERS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2365 E SEGOVIA DR
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7487
Mailing Address - Country:US
Mailing Address - Phone:435-773-5585
Mailing Address - Fax:
Practice Address - Street 1:2365 E SEGOVIA DR
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7487
Practice Address - Country:US
Practice Address - Phone:435-773-5585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201160004CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered