Provider Demographics
NPI:1306382320
Name:WILLIAMS, JALISA
Entity Type:Individual
Prefix:
First Name:JALISA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10825 KEY HAVEN BLVD APT 604
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-6423
Mailing Address - Country:US
Mailing Address - Phone:904-599-1759
Mailing Address - Fax:904-683-9484
Practice Address - Street 1:10825 KEY HAVEN BLVD APT 604
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-6423
Practice Address - Country:US
Practice Address - Phone:904-599-1759
Practice Address - Fax:904-683-9484
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker