Basic Information
| Provider Information | |||||||||
| NPI: | 1609480359 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATTERS | ||||||||
| FirstName: | JACOB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2971 INTERSTATE AVE | ||||||||
| Address2: | |||||||||
| City: | ARCO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832138705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013675004 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2700 NW STEWART PKWY | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974711281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416730611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2020 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA201167 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.