Healthcare Provider Details

I. General information

NPI: 1811029572
Provider Name (Legal Business Name): JENNIFER JANE WATERMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 W BETHEL AVE
MUNCIE IN
47304-5407
US

IV. Provider business mailing address

3600 W BETHEL AVE
MUNCIE IN
47304-5407
US

V. Phone/Fax

Practice location:
  • Phone: 800-622-6575
  • Fax:
Mailing address:
  • Phone: 800-622-6575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberINACTIVE
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAO3379
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002212A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: