Provider Demographics
NPI:1710485354
Name:WATSON, JACOB RAY
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:RAY
Last Name:WATSON
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 1:14317 POTRANCO ROARD SUITE 205, #327
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253
Mailing Address - Country:US
Mailing Address - Phone:210-672-0564
Mailing Address - Fax:
Practice Address - Street 1:9274 INGLETON
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-1659
Practice Address - Country:US
Practice Address - Phone:210-672-0564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-17-36085106S00000X
TX1-20-42381103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician