Provider Demographics
NPI:1275878142
Name:WILLIAMS, JACK PARKER (LPTA)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:PARKER
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5690 WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT
Mailing Address - State:OH
Mailing Address - Zip Code:44030
Mailing Address - Country:US
Mailing Address - Phone:440-813-4223
Mailing Address - Fax:
Practice Address - Street 1:5690 WEAVER RD
Practice Address - Street 2:
Practice Address - City:CONNEAUT
Practice Address - State:OH
Practice Address - Zip Code:44030-9798
Practice Address - Country:US
Practice Address - Phone:440-813-4223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH870225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant