Healthcare Provider Details

I. General information

NPI: 1215430913
Provider Name (Legal Business Name): JASMINE WILLIAMSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date: 06/20/2024
Reactivation Date: 07/25/2024

III. Provider practice location address

745 ELA RD
LAKE ZURICH IL
60047-2337
US

IV. Provider business mailing address

745 ELA RD
LAKE ZURICH IL
60047-2337
US

V. Phone/Fax

Practice location:
  • Phone: 760-484-8805
  • Fax:
Mailing address:
  • Phone: 708-888-4012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number12043473
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: