Provider Demographics
NPI:1972292753
Name:WILLIAMS, JEANINE
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 S MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-5101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4211
Practice Address - Country:US
Practice Address - Phone:626-857-0633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA276231164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse