Provider Demographics
NPI:1225881204
Name:WILLIAMS, JESSICA LAINE
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LAINE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LAINE
Other - Last Name:DIEBEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1514 FELICE LN
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-7449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 BRYAN DR STE 208
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-2157
Practice Address - Country:US
Practice Address - Phone:580-920-9063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-09
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK216889363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily