Provider Demographics
NPI:1538162045
Name:WATSON, JEROME BRADFIELD (GNP)
Entity type:Individual
Prefix:MR
First Name:JEROME
Middle Name:BRADFIELD
Last Name:WATSON
Suffix:
Gender:M
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7209 GOLDFINCH RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-0227
Mailing Address - Country:US
Mailing Address - Phone:903-334-8132
Mailing Address - Fax:903-334-8146
Practice Address - Street 1:7209 GOLDFINCH RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-0227
Practice Address - Country:US
Practice Address - Phone:903-334-8132
Practice Address - Fax:903-334-8146
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-30
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX605190363LG0600X
TXAP108606363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100082540AMedicaid
TX500004259OtherRAILROAD MEDICARE
TXP00267929OtherTX RAILROAD MEDICARE
TX029325001Medicaid
AR5U081OtherMEDICARE - LEGACY NUMBER
AR145430758Medicaid
AR160262762Medicaid
TX29325004Medicaid
TX029325002Medicaid
AR500004259OtherRAILROAD MEDICARE
TX8D9579OtherMEDICARE - LEGACY NUMBER
TX029325002Medicaid