Provider Demographics
NPI:1619189818
Name:WILLIAMS, JAN D (MED)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:D
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 BOSTONIAN TRCE
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-5627
Mailing Address - Country:US
Mailing Address - Phone:770-363-1929
Mailing Address - Fax:
Practice Address - Street 1:704 BOSTONIAN TRCE
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-5627
Practice Address - Country:US
Practice Address - Phone:770-363-1929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003905235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA891207907AMedicaid