Provider Demographics
NPI:1891286191
Name:WILLIAMS, JEFFERSON (LCPC)
Entity Type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N VETERANS PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-3568
Mailing Address - Country:US
Mailing Address - Phone:309-663-2229
Mailing Address - Fax:
Practice Address - Street 1:211 N VETERANS PKWY STE 1
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3568
Practice Address - Country:US
Practice Address - Phone:309-663-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004426101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional