Provider Demographics
NPI:1639215361
Name:WILLIAMS, JACQUELINE G (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:G
Last Name:WILLIAMS
Suffix:
Gender:F
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:PO BOX 66208
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70896-6208
Mailing Address - Country:US
Mailing Address - Phone:225-765-7144
Mailing Address - Fax:225-765-7115
Practice Address - Street 1:7516 PICARDY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4333
Practice Address - Country:US
Practice Address - Phone:225-765-7144
Practice Address - Fax:225-765-7115
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017029208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1337358Medicaid