Healthcare Provider Details

I. General information

NPI: 1558032227
Provider Name (Legal Business Name): JADRIAN DB WATKINS PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 COLONIAL DR
YOUNGSTOWN OH
44505-2139
US

IV. Provider business mailing address

196 COLONIAL DR
YOUNGSTOWN OH
44505-2139
US

V. Phone/Fax

Practice location:
  • Phone: 330-322-2348
  • Fax:
Mailing address:
  • Phone: 330-322-2348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN.CNP.0030687
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN.460025
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: