Provider Demographics
NPI:1356663058
Name:WILLIAMS, IDA M
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:M
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 1:1804 HIGHWAY 45 BYP
Mailing Address - Street 2:SUITE 604
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4436
Mailing Address - Country:US
Mailing Address - Phone:731-512-1571
Mailing Address - Fax:731-660-8739
Practice Address - Street 1:759 W CHURCH ST
Practice Address - Street 2:SUITES 7 & 8
Practice Address - City:LEXINGTON
Practice Address - State:TN
Practice Address - Zip Code:38351-1738
Practice Address - Country:US
Practice Address - Phone:731-968-8197
Practice Address - Fax:731-967-1749
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator