Healthcare Provider Details

I. General information

NPI: 1750899696
Provider Name (Legal Business Name): JEZELLE MERCEDES WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JEZELLE MERCEDES DONOR

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2836 KIMBERLIE CT
ANCHORAGE AK
99508-5329
US

IV. Provider business mailing address

2836 KIMBERLIE CT
ANCHORAGE AK
99508-5329
US

V. Phone/Fax

Practice location:
  • Phone: 907-349-4222
  • Fax:
Mailing address:
  • Phone: 907-349-4222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number160249
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: