Provider Demographics
NPI:1336010347
Name:WATERMAN, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:WATERMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:926 E COAST DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-5426
Mailing Address - Country:US
Mailing Address - Phone:904-910-0014
Mailing Address - Fax:
Practice Address - Street 1:6600 CHARING ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6110
Practice Address - Country:US
Practice Address - Phone:904-674-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11042190367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife