Provider Demographics
NPI:1093124091
Name:WILLIAMS, JERONE
Entity Type:Individual
Prefix:
First Name:JERONE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 JACKSON AVE
Mailing Address - Street 2:BREAKTHROUGH BELIEVERS
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-1114
Mailing Address - Country:US
Mailing Address - Phone:231-343-2753
Mailing Address - Fax:
Practice Address - Street 1:349 JACKSON AVE
Practice Address - Street 2:BREAKTHROUGH BELIEVERS
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-1114
Practice Address - Country:US
Practice Address - Phone:231-343-2753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171M00000X, 171W00000X, 172V00000X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1376866160Medicaid
MI1376866160Medicaid