Provider Demographics
NPI:1982866802
Name:WILLIAMSON, JAN-DOREEN (OTR/L)
Entity Type:Individual
Prefix:
First Name:JAN-DOREEN
Middle Name:
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 CASTLE ROCK DR
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:42539-8144
Mailing Address - Country:US
Mailing Address - Phone:606-346-3295
Mailing Address - Fax:
Practice Address - Street 1:616 S WALLACE WILKINSON BLVD
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:42539-3344
Practice Address - Country:US
Practice Address - Phone:606-787-6889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR2415314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY$$$$$$$$$OtherNIP