Healthcare Provider Details

I. General information

NPI: 1043478225
Provider Name (Legal Business Name): DOMINIQUE JAMISON-WILLAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2008
Last Update Date: 05/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 ARTHUR ST
MERRILLVILLE IN
46410-3123
US

IV. Provider business mailing address

6400 ARTHUR ST
MERRILLVILLE IN
46410-3123
US

V. Phone/Fax

Practice location:
  • Phone: 219-981-8551
  • Fax:
Mailing address:
  • Phone: 219-981-8551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number31002428A
License Number StateIN

VIII. Authorized Official

Name: DOMINIQUE LASHANDA JAMISOM-WILLIAMS
Title or Position: OCCUPATIONAL THERAPIST
Credential: MSOTR
Phone: 219-981-8551