Provider Demographics
NPI:1912580788
Name:WILLIAMS, JORDAN TAMAYIA
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:TAMAYIA
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 1:518 OAKLAND AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2343
Mailing Address - Country:US
Mailing Address - Phone:864-395-4753
Mailing Address - Fax:
Practice Address - Street 1:710 E CATAWBA ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-3504
Practice Address - Country:US
Practice Address - Phone:864-395-4753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-21-180856106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician