Provider Demographics
NPI:1992332712
Name:WILLIAMS, JESSICA ANN (DO)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ANN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1809 S MAIN ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:IN
Practice Address - Zip Code:46989-9257
Practice Address - Country:US
Practice Address - Phone:765-770-0650
Practice Address - Fax:765-770-0652
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN02006716A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300039089Medicaid
INM22404301OtherMEDICARE PTAN