Provider Demographics
NPI:1568715035
Name:WATT, JENNIFER (LPN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WATT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 646
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-0646
Mailing Address - Country:US
Mailing Address - Phone:516-371-5981
Mailing Address - Fax:
Practice Address - Street 1:220 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1542
Practice Address - Country:US
Practice Address - Phone:516-371-5981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284872164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse