Basic Information
Provider Information
NPI: 1053777631
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WILLIAMS
FirstName: JENNA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: ATC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 46 E CHILLICOTHE ST
Address2: P.O. BOX 235
City: CEDARVILLE
State: OH
PostalCode: 453149609
CountryCode: US
TelephoneNumber: 9375723163
FaxNumber:  
Practice Location
Address1: 2400 MIAMI VALLEY DR
Address2:  
City: CENTERVILLE
State: OH
PostalCode: 454594774
CountryCode: US
TelephoneNumber: 9374382400
FaxNumber:  
Other Information
ProviderEnumerationDate: 01/12/2016
LastUpdateDate: 01/12/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
282N00000XAT.004599OHY HospitalsGeneral Acute Care Hospital 

No ID Information.


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