Provider Demographics
NPI:1457724866
Name:WATSON, JACQUELYN LEAH (FNP-C)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:LEAH
Last Name:WATSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 PIPERS CT
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-3485
Mailing Address - Country:US
Mailing Address - Phone:636-575-0582
Mailing Address - Fax:
Practice Address - Street 1:722 LOUGHBOROUGH AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63111-2732
Practice Address - Country:US
Practice Address - Phone:314-833-4030
Practice Address - Fax:314-833-4031
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015040599363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily