=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417891243
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK THOMAS WATSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2026
-----------------------------------------------------
Last Update Date | 04/14/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1201 W 12TH AVE
-----------------------------------------------------
City | EMPORIA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66801-2504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-343-6800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7400 W 37TH ST N APT 416
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67205-3322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-320-0274
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------