Provider Demographics
NPI:1912133919
Name:WATTERS, JENNIFER M (DC, LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:WATTERS
Suffix:
Gender:F
Credentials:DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 E OCEAN BLVD UNIT 309
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-5534
Mailing Address - Country:US
Mailing Address - Phone:310-977-5779
Mailing Address - Fax:
Practice Address - Street 1:710 WILSHIRE BLVD STE 314
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1724
Practice Address - Country:US
Practice Address - Phone:310-977-5779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31258111N00000X
CA13668171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist