Provider Demographics
NPI:1053687913
Name:WILLIAMS- JACKSON, MICHELLE A (RN, BSN)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:A
Last Name:WILLIAMS- JACKSON
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-2907
Mailing Address - Country:US
Mailing Address - Phone:215-744-6048
Mailing Address - Fax:
Practice Address - Street 1:1930 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2328
Practice Address - Country:US
Practice Address - Phone:215-339-4563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA574196163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse