Provider Demographics
NPI:1508287921
Name:WILLIAMS-JACKSON, ROBERTNIQUE WAYNETTE
Entity Type:Individual
Prefix:
First Name:ROBERTNIQUE
Middle Name:WAYNETTE
Last Name:WILLIAMS-JACKSON
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 1:103 4TH ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71251-3346
Mailing Address - Country:US
Mailing Address - Phone:318-259-1500
Mailing Address - Fax:318-259-1580
Practice Address - Street 1:103 4TH ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:LA
Practice Address - Zip Code:71251
Practice Address - Country:US
Practice Address - Phone:318-259-1500
Practice Address - Fax:318-259-1580
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA462049116171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator