Provider Demographics
NPI:1528893534
Name:WILLIAMS, JEANINE (LCAC-A)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LCAC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8448 E 100 N
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-8741
Mailing Address - Country:US
Mailing Address - Phone:765-491-1952
Mailing Address - Fax:
Practice Address - Street 1:200 FERRY ST STE B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47901-1172
Practice Address - Country:US
Practice Address - Phone:765-268-0183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87900095A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)