Provider Demographics
NPI:1275641664
Name:WILLIAMS, JENNIFER WATERS (PHD)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:WATERS
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 ASHMORE LANE
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-1774
Mailing Address - Country:US
Mailing Address - Phone:252-451-1171
Mailing Address - Fax:
Practice Address - Street 1:878 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-1707
Practice Address - Country:US
Practice Address - Phone:252-314-7021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4038103T00000X, 103TC0700X
NC1388103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1427010578OtherMEDICARE
NC2826021OtherMEDICARE PTAN
NC561396133OtherMEDCOST
NC561396133OtherAETNA
NC015WAOtherBCBS OF NC
NC561396133OtherTRICARE
NC561396133OtherCIGNA
NC2351764Medicare PIN