Provider Demographics
NPI:1679371777
Name:WILLIAMS, JACARA
Entity type:Individual
Prefix:
First Name:JACARA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 RIDGE VIEW XING
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3310
Mailing Address - Country:US
Mailing Address - Phone:470-715-8736
Mailing Address - Fax:
Practice Address - Street 1:529 RIDGE VIEW XING
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3310
Practice Address - Country:US
Practice Address - Phone:470-715-8736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA070456185172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver