Provider Demographics
NPI:1568548790
Name:WILLIAMS, JANSSEN JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:JANSSEN
Middle Name:JACOB
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-1167
Mailing Address - Country:US
Mailing Address - Phone:618-546-5464
Mailing Address - Fax:
Practice Address - Street 1:4303 JODECO RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8297
Practice Address - Country:US
Practice Address - Phone:618-546-5464
Practice Address - Fax:618-546-2648
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19536207R00000X
IN01076261A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF50973Medicare UPIN