Provider Demographics
NPI:1962651638
Name:WATSON, JACQUELINE A (LPN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:A
Last Name:WATSON
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 1:81 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-3257
Mailing Address - Country:US
Mailing Address - Phone:631-351-5346
Mailing Address - Fax:
Practice Address - Street 1:81 E 21ST ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-3257
Practice Address - Country:US
Practice Address - Phone:631-351-5346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215581-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse