Individual
JENNA MARIE WATERMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
7333 W JEFFERSON BLVD, FORT WAYNE, IN 46804-6202
(383) 026-0458
Mailing address
7333 W JEFFERSON BLVD, FORT WAYNE, IN 46804-6202
(383) 026-0458
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
10002636A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
300021873
—
IN
Enumeration date
12/21/2018
Last updated
09/21/2020
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