Provider Demographics
NPI:1922538503
Name:WATSON, JACQUELINE KATRINA (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KATRINA
Last Name:WATSON
Suffix:
Gender:F
Credentials:MD
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9955 POPLAR TENT RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-9314
Practice Address - Country:US
Practice Address - Phone:704-316-1161
Practice Address - Fax:704-316-1162
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC228149207Q00000X
NC2020-03659207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine