Provider Demographics
NPI:1922298975
Name:WILLIAMS, JACKIE L (MS, LADC)
Entity Type:Individual
Prefix:MS
First Name:JACKIE
Middle Name:L
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MS, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-0189
Mailing Address - Country:US
Mailing Address - Phone:580-223-5070
Mailing Address - Fax:580-223-5617
Practice Address - Street 1:2530 SOUTH COMMERCE
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401
Practice Address - Country:US
Practice Address - Phone:580-223-5070
Practice Address - Fax:580-223-5617
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK578101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)