Provider Demographics
NPI:1730661661
Name:WILLIAMS, GLORIA JACKSON (ST)
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:JACKSON
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 ARISTEDES RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-7745
Mailing Address - Country:US
Mailing Address - Phone:229-296-3647
Mailing Address - Fax:
Practice Address - Street 1:3430 ARISTEDES RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721-7745
Practice Address - Country:US
Practice Address - Phone:229-296-3647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor