Basic Information
| Provider Information | |||||||||
| NPI: | 1710949656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3433 BROADWAY ST NE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554131761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635877737 | ||||||||
| FaxNumber: | 7635877069 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 E 28TH ST | ||||||||
| Address2: | 250 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554073723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128635665 | ||||||||
| FaxNumber: | 6128634144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 41763 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 128436300 | 05 | MN | MEDICAID |