Basic Information
| Provider Information | |||||||||
| NPI: | 1013368679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 E EDGEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338034014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636192809 | ||||||||
| FaxNumber: | 8636449590 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 E EDGEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338034014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136192809 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2016 | ||||||||
| LastUpdateDate: | 02/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-19-35657 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 019575500 | 05 | FL | MEDICAID |