Provider Demographics
NPI:1053777631
Name:WILLIAMS, JENNA (ATC)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 E CHILLICOTHE ST
Mailing Address - Street 2:P.O. BOX 235
Mailing Address - City:CEDARVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45314-9609
Mailing Address - Country:US
Mailing Address - Phone:937-572-3163
Mailing Address - Fax:
Practice Address - Street 1:2400 MIAMI VALLEY DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4774
Practice Address - Country:US
Practice Address - Phone:937-438-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT.004599282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital