Provider Demographics
NPI:1033405147
Name:WILLIAMS, JENNIFER MARY (LAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MARY
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MARY
Other - Last Name:BROGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:2817 REILLY ROAD MCXC-COD CREDENTIALS
Mailing Address - Street 2:WOMACK ARMY MEDICAL CENTER
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310
Mailing Address - Country:US
Mailing Address - Phone:910-907-8922
Mailing Address - Fax:910-907-6069
Practice Address - Street 1:2817 REILLY ROAD MCXC-COD CREDENTIALS
Practice Address - Street 2:WOMACK ARMY MEDICAL CENTER
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310
Practice Address - Country:US
Practice Address - Phone:910-907-8922
Practice Address - Fax:910-907-6069
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC553171100000X
VA0121000568171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist