Provider Demographics
NPI:1093137580
Name:WILLIAMS, JASON
Entity Type:Individual
Prefix:
First Name:JASON
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 1:6700 WASHINGTON AVE S
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3405
Mailing Address - Country:US
Mailing Address - Phone:612-351-1529
Mailing Address - Fax:
Practice Address - Street 1:522 US HIGHWAY 79 S STE B
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75654-3641
Practice Address - Country:US
Practice Address - Phone:903-657-1702
Practice Address - Fax:903-657-4560
Is Sole Proprietor?:No
Enumeration Date:2014-01-17
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX237600000X
TX80409237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2205718-01Medicaid