Basic Information
| Provider Information | |||||||||
| NPI: | 1588117105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 160TH ST S | ||||||||
| Address2: | STE. 301 | ||||||||
| City: | SPANAWAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983878508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535314100 | ||||||||
| FaxNumber: | 2535313795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2016 | ||||||||
| LastUpdateDate: | 08/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DI60665703 | WA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | DI60665703 | 01 | WA | STATE LICENSE | OTHER |