MEDICARE: JALEEL WATSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver		FL

General Provider Information

NPI Number	:	1023663648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JALEEL WATSON

Provider Business Mailing Address
First Line	:	1060 PETER RD
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-1732
Country	:	US
Telephone Number	:	321-745-5100
Fax Number	:

Provider Business Practice Location Address
First Line	:	1060 PETER RD
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-1732
Country	:	US
Telephone Number	:	321-745-5100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2019
Last Update Date	:	08/09/2019

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Directions to “ JALEEL WATSON ” Practice Location

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