Provider Demographics
NPI:1639217722
Name:WILLILAMS-BLAKEY, JACQUELYN (OD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
Last Name:WILLILAMS-BLAKEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18331 FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221
Mailing Address - Country:US
Mailing Address - Phone:313-863-8387
Mailing Address - Fax:
Practice Address - Street 1:71 GARFIELD ST.
Practice Address - Street 2:STE. 180
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1911
Practice Address - Country:US
Practice Address - Phone:313-974-7299
Practice Address - Fax:313-974-7525
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJW003785152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION21350Medicare ID - Type Unspecified
MIU82807Medicare UPIN
MI5674001Medicare PIN