Provider Demographics
NPI:1811029572
Name:WATERMAN, JENNIFER JANE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JANE
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 W BETHEL AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5407
Mailing Address - Country:US
Mailing Address - Phone:800-622-6575
Mailing Address - Fax:
Practice Address - Street 1:3600 W BETHEL AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5407
Practice Address - Country:US
Practice Address - Phone:800-622-6575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEINACTIVE363A00000X
TXPAO3379363A00000X
IN10002212A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant