Healthcare Provider Details

I. General information

NPI: 1124494513
Provider Name (Legal Business Name): JODI WATSON ROSE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JODI L WATSON NP

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2253 CHAMBLISS AVE NW STE 301
CLEVELAND TN
37311-3961
US

IV. Provider business mailing address

2253 CHAMBLISS AVE NW STE 301
CLEVELAND TN
37311-3961
US

V. Phone/Fax

Practice location:
  • Phone: 423-476-5002
  • Fax: 423-339-4466
Mailing address:
  • Phone: 423-476-5002
  • Fax: 423-339-4466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000020261
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: