Provider Demographics
NPI:1831824465
Name:WILLIAMS, JACOB LEE
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:LEE
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 1:1350 HIGHWAY 120
Mailing Address - Street 2:
Mailing Address - City:BIG ROCK
Mailing Address - State:TN
Mailing Address - Zip Code:37023-3013
Mailing Address - Country:US
Mailing Address - Phone:931-627-9101
Mailing Address - Fax:
Practice Address - Street 1:110 DOVER CROSSING RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-4165
Practice Address - Country:US
Practice Address - Phone:931-920-8684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN46325183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist