Healthcare Provider Details

I. General information

NPI: 1760395644
Provider Name (Legal Business Name): JADA WATKINS
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 SANDY DR STE D
STATE COLLEGE PA
16803-2205
US

IV. Provider business mailing address

2160 SANDY DR STE D
STATE COLLEGE PA
16803-2205
US

V. Phone/Fax

Practice location:
  • Phone: 814-380-9180
  • Fax:
Mailing address:
  • Phone: 814-380-9180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBH008792
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: