Provider Demographics
NPI:1548869571
Name:WATERSJACKSON, JOSHUA (ATC)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:WATERSJACKSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2865
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92051-2865
Mailing Address - Country:US
Mailing Address - Phone:760-917-5920
Mailing Address - Fax:
Practice Address - Street 1:430406 LAS PULGAS
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-917-5920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer