Provider Demographics
NPI:1912197724
Name:WILLIAMS, JERMAINE DELVONTAE
Entity Type:Individual
Prefix:
First Name:JERMAINE
Middle Name:DELVONTAE
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 1:13915 ALFELD AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90061-2123
Mailing Address - Country:US
Mailing Address - Phone:310-217-0579
Mailing Address - Fax:
Practice Address - Street 1:8019 S. COMPTON AVE.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001
Practice Address - Country:US
Practice Address - Phone:323-586-7333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner