Provider Demographics
NPI:1851874341
Name:WILLIAMS, JENNIFER KAY (PTA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:KAY
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:KAY
Other - Last Name:WEGMILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1717 CALICO LN
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-1690
Mailing Address - Country:US
Mailing Address - Phone:580-747-2064
Mailing Address - Fax:
Practice Address - Street 1:401 S 3RD ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5737
Practice Address - Country:US
Practice Address - Phone:580-548-1164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2004225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant