Provider Demographics
NPI:1336581669
Name:WILLIAMS, JEAN MAXINE
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:MAXINE
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 1:7108 S SHAMROCK RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33616-2135
Mailing Address - Country:US
Mailing Address - Phone:813-831-6795
Mailing Address - Fax:
Practice Address - Street 1:7108 S SHAMROCK RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33616-2135
Practice Address - Country:US
Practice Address - Phone:813-831-6795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL141491700Medicaid