=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073644837
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMY BEAU WATSON M.A., MFTI
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15317 RAYEN ST
-----------------------------------------------------
City | NORTH HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91343-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-892-3423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22111 CALVERT ST APT 218
-----------------------------------------------------
City | WOODLAND HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91367-3570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-497-2937
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 50579
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------