Provider Demographics
NPI:1861433393
Name:WATSON, JAKE JR (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:JAKE
Middle Name:
Last Name:WATSON
Suffix:JR
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MR
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:WATSON
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:3731 S NORTON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-4046
Mailing Address - Country:US
Mailing Address - Phone:323-296-2388
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14184363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical