Healthcare Provider Details

I. General information

NPI: 1265637870
Provider Name (Legal Business Name): JENNIFER RENAE WILLIAMS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 GAUSE BLVD FIRST FLOOR
SLIDELL LA
70458-2937
US

IV. Provider business mailing address

508 FULTON ST # 11C
DURHAM NC
27705-3875
US

V. Phone/Fax

Practice location:
  • Phone: 985-280-8971
  • Fax: 985-280-2618
Mailing address:
  • Phone: 919-286-6963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116019549
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60079331
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD203638
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: