Provider Demographics
NPI:1205563681
Name:WILLIAMS, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W6397 SONNY DR APT 9
Mailing Address - Street 2:
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-9025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:828 FOX POINT PLZ
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-3781
Practice Address - Country:US
Practice Address - Phone:920-722-1348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21379-401835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist