Provider Demographics
NPI:1801371422
Name:GILLIAM, JEANNETTA
Entity Type:Individual
Prefix:
First Name:JEANNETTA
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:
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 388
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-0388
Mailing Address - Country:US
Mailing Address - Phone:870-208-9333
Mailing Address - Fax:
Practice Address - Street 1:205 W BOND AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-3907
Practice Address - Country:US
Practice Address - Phone:870-208-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor