Provider Demographics
NPI:1881016202
Name:WILLIAMS, JIBU (DC)
Entity Type:Individual
Prefix:
First Name:JIBU
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1499 W YAMATO RD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-4435
Mailing Address - Country:US
Mailing Address - Phone:612-085-9285
Mailing Address - Fax:
Practice Address - Street 1:1499 W YAMATO RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431
Practice Address - Country:US
Practice Address - Phone:561-208-5928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-21
Last Update Date:2018-07-13
Deactivation Date:2018-02-20
Deactivation Code:
Reactivation Date:2018-04-12
Provider Licenses
StateLicense IDTaxonomies
FLCH10946111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor