Provider Demographics
NPI:1093392730
Name:WILLIAMS, JELISSA (MS, LBA)
Entity Type:Individual
Prefix:
First Name:JELISSA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MS, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4420 HELMS DR
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:AL
Mailing Address - Zip Code:36054-4105
Mailing Address - Country:US
Mailing Address - Phone:334-380-1740
Mailing Address - Fax:
Practice Address - Street 1:200 VESTAVIA PKWY
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35216-7715
Practice Address - Country:US
Practice Address - Phone:205-490-5364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12148631103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst