Provider Demographics
NPI:1740670355
Name:WATSON, JORDAN MATTHEW
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MATTHEW
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 1:1635 HULMAN WAYE CT
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-3893
Mailing Address - Country:US
Mailing Address - Phone:812-249-8222
Mailing Address - Fax:
Practice Address - Street 1:1635 HULMAN WAYE CT
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47803-3893
Practice Address - Country:US
Practice Address - Phone:812-249-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer