Provider Demographics
NPI:1043478225
Name:DOMINIQUE JAMISON-WILLAMS
Entity Type:Organization
Organization Name:DOMINIQUE JAMISON-WILLAMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:LASHANDA
Authorized Official - Last Name:JAMISOM-WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MSOTR
Authorized Official - Phone:219-981-8551
Mailing Address - Street 1:6400 ARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-3123
Mailing Address - Country:US
Mailing Address - Phone:219-981-8551
Mailing Address - Fax:
Practice Address - Street 1:6400 ARTHUR ST
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-3123
Practice Address - Country:US
Practice Address - Phone:219-981-8551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-24
Last Update Date:2008-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31002428A252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200610120Medicaid
IN200708930Medicaid