Provider Demographics
NPI:1285071738
Name:WILLIAMS, JACKIE AUGUSTUS (MD)
Entity type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:AUGUSTUS
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7227 S LUELLA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649-2513
Mailing Address - Country:US
Mailing Address - Phone:773-493-9637
Mailing Address - Fax:
Practice Address - Street 1:7556 JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130-1854
Practice Address - Country:US
Practice Address - Phone:708-838-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.060095207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology