Healthcare Provider Details

I. General information

NPI: 1548899156
Provider Name (Legal Business Name): JORDYN L WATTS ACNPC-AG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 6TH ST
LEWISTON ID
83501-2431
US

IV. Provider business mailing address

1400 E CACTUS AVE
POST FALLS ID
83854-6066
US

V. Phone/Fax

Practice location:
  • Phone: 208-743-2511
  • Fax:
Mailing address:
  • Phone: 208-365-8161
  • Fax: 877-389-5153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP61063402
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number68454
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60283274
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: