Provider Demographics
NPI:1376872549
Name:WATTS, JESSICA LYNN (CMI)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:WATTS
Suffix:
Gender:F
Credentials:CMI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-6237
Mailing Address - Country:US
Mailing Address - Phone:580-326-7477
Mailing Address - Fax:580-326-6400
Practice Address - Street 1:1005 S 5TH ST BLDG 4
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-8013
Practice Address - Country:US
Practice Address - Phone:580-406-2816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-16
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK300163171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator