Provider Demographics
NPI:1902028087
Name:WILLIAMS, JERRY LEE
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LEE
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:962 W 42ND PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-2511
Mailing Address - Country:US
Mailing Address - Phone:323-738-6172
Mailing Address - Fax:323-294-6400
Practice Address - Street 1:4041 MARLTON AVE
Practice Address - Street 2:SUITE 136
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-2519
Practice Address - Country:US
Practice Address - Phone:323-294-6400
Practice Address - Fax:323-294-6400
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)