Healthcare Provider Details

I. General information

NPI: 1306048442
Provider Name (Legal Business Name): JENNIFER J. WATSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER J. WILLIAMS M.D.

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4069 LAKE DR SE SUITE 114
GRAND RAPIDS MI
49546-8816
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-8346
  • Fax: 616-940-8004
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLP01109
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number4301101424
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: