Provider Demographics
NPI:1992717805
Name:WILLIAMS, JACQUELINE M (MS, LAT, ATC)
Entity type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:M
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 VANDAL DR
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-9229
Mailing Address - Country:US
Mailing Address - Phone:208-882-7140
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF IDAHO
Practice Address - Street 2:DEPT. OF HPERD PEB 100
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83844-2401
Practice Address - Country:US
Practice Address - Phone:208-885-2185
Practice Address - Fax:208-885-5929
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-1062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer