Provider Demographics
NPI:1023588316
Name:WILLIAMS, JACKLYN (OTA)
Entity type:Individual
Prefix:
First Name:JACKLYN
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19121 PENCIL CACTUS DR
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-5454
Mailing Address - Country:US
Mailing Address - Phone:512-800-9705
Mailing Address - Fax:
Practice Address - Street 1:2001 SCENIC DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7725
Practice Address - Country:US
Practice Address - Phone:512-863-9511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210218224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant