Provider Demographics
NPI:1134362189
Name:WILLIAMS, PRUDENCE CLARKE (MSW)
Entity type:Individual
Prefix:
First Name:PRUDENCE
Middle Name:CLARKE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12127 CRANEFOOT DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-4826
Mailing Address - Country:US
Mailing Address - Phone:904-553-3502
Mailing Address - Fax:
Practice Address - Street 1:1536 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6525
Practice Address - Country:US
Practice Address - Phone:904-553-3502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-07
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
FLISW484104100000X
FLSW96261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL681935496Medicaid