1861787277 NPI number — MR. JEROME EVERETTE WATSON SR. LMFT

Table of content: MR. JEROME EVERETTE WATSON SR. LMFT (NPI 1861787277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861787277 NPI number — MR. JEROME EVERETTE WATSON SR. LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATSON
Provider First Name:
JEROME
Provider Middle Name:
EVERETTE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
LMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861787277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16333 GREEN TREE BLVD UNIT 2673
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VICTORVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92393-7108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-915-4998
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12180 RIDGECREST RD STE 402A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VICTORVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92395-5902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-881-3558
Provider Business Practice Location Address Fax Number:
760-881-3457
Provider Enumeration Date:
06/14/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MFC 48090 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)