Basic Information
| Provider Information | |||||||||
| NPI: | 1932722253 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | JENNY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 S JEFFERSON ST STE 1006 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240111713 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5610 WILLIAMSON RD | ||||||||
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| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240121442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402658924 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2020 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 0024178837 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 000000 | 01 | NOT APPLICABLE | OTHER |