Provider Demographics
NPI:1366209793
Name:WILLIAMS, JACKIE FLORENCE
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:FLORENCE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 GRAFTON AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6906
Mailing Address - Country:US
Mailing Address - Phone:651-726-4719
Mailing Address - Fax:
Practice Address - Street 1:239 GRAFTON AVE N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-6906
Practice Address - Country:US
Practice Address - Phone:651-726-4719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant