Provider Demographics
NPI:1114261021
Name:WILLETT, TIMOTHY JASON (HAS)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JASON
Last Name:WILLETT
Suffix:
Gender:M
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 RIDGEWOOD AVE # B
Mailing Address - Street 2:
Mailing Address - City:HOLLY HILL
Mailing Address - State:FL
Mailing Address - Zip Code:32117-1798
Mailing Address - Country:US
Mailing Address - Phone:386-673-3366
Mailing Address - Fax:386-615-0990
Practice Address - Street 1:1615 RIDGEWOOD AVE # B
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:FL
Practice Address - Zip Code:32117-1798
Practice Address - Country:US
Practice Address - Phone:386-673-3366
Practice Address - Fax:386-615-0990
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS 4908237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist