Healthcare Provider Details

I. General information

NPI: 1982460374
Provider Name (Legal Business Name): JESSE LEE WATSON SR. M.DIV; BCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E STONER AVE
SHREVEPORT LA
71101-4243
US

IV. Provider business mailing address

1651 E 70TH ST # 285
SHREVEPORT LA
71105-5115
US

V. Phone/Fax

Practice location:
  • Phone: 318-990-5807
  • Fax:
Mailing address:
  • Phone: 189-990-5807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: