Healthcare Provider Details

I. General information

NPI: 1548552920
Provider Name (Legal Business Name): JENNA NOLAN WATSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA MARIE NOLAN

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10800 MAGNOLIA AVE
RIVERSIDE CA
92505-3043
US

IV. Provider business mailing address

29333 OAKMONT CT
MURRIETA CA
92563-5816
US

V. Phone/Fax

Practice location:
  • Phone: 866-984-7483
  • Fax:
Mailing address:
  • Phone: 951-440-9343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA122335
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: