Provider Demographics
NPI:1609480359
Name:WATTERS, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WATTERS
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 1:2971 INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:ARCO
Mailing Address - State:ID
Mailing Address - Zip Code:83213-8705
Mailing Address - Country:US
Mailing Address - Phone:801-367-5004
Mailing Address - Fax:
Practice Address - Street 1:2700 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1281
Practice Address - Country:US
Practice Address - Phone:541-673-0611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA201167363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant