Basic Information
| Provider Information | |||||||||
| NPI: | 1093137580 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | JASON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6700 WASHINGTON AVE S | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123511529 | ||||||||
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| Practice Location | |||||||||
| Address1: | 522 US HIGHWAY 79 S STE B | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756543641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036571702 | ||||||||
| FaxNumber: | 9036574560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2014 | ||||||||
| LastUpdateDate: | 12/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | TX | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237700000X | 80409 | TX | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2205718-01 | 05 | TX | MEDICAID |