MEDICARE: MR. JON RICHARD WATASE

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	103K00000X	Behavior Analyst
2	104100000X	Social Worker

General Provider Information

NPI Number	:	1033400114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JON RICHARD WATASE

Provider Business Mailing Address
First Line	:	6298 MESOSPHERE CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-5043
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8608 DESERT HOLLY DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-8851
Country	:	US
Telephone Number	:	702-400-3819
Fax Number	:

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

Provider Enumeration Date	:	04/25/2011
Last Update Date	:	05/10/2023

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