Provider Demographics
NPI:1831454842
Name:WATSON, JENNIFER B (PTA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:B
Last Name:WATSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 FIRESIDE LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-7638
Mailing Address - Country:US
Mailing Address - Phone:336-325-6551
Mailing Address - Fax:
Practice Address - Street 1:228 FIRESIDE LN
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-7638
Practice Address - Country:US
Practice Address - Phone:336-325-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4792225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant