Basic Information
| Provider Information | |||||||||
| NPI: | 1073035168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 W VAN DORN AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386352902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622743212 | ||||||||
| FaxNumber: | 6622743213 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 W VAN DORN AVE | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386352902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622743212 | ||||||||
| FaxNumber: | 6622743213 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2017 | ||||||||
| LastUpdateDate: | 07/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A005207 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 902114 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.