Provider Demographics
NPI:1679824221
Name:WILLIAMS, JENNIFER RUTH (OTR)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RUTH
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E TYLER ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-7224
Mailing Address - Country:US
Mailing Address - Phone:903-600-6797
Mailing Address - Fax:972-470-5875
Practice Address - Street 1:110 E TYLER ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601
Practice Address - Country:US
Practice Address - Phone:903-600-6797
Practice Address - Fax:903-600-6801
Is Sole Proprietor?:No
Enumeration Date:2012-09-23
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113636225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist