Healthcare Provider Details

I. General information

NPI: 1952163438
Provider Name (Legal Business Name): JESSICA MARIE WILLIAMS PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W 10TH ST
ROLLA MO
65401-3247
US

IV. Provider business mailing address

PO BOX 554
BELLE MO
65013-0554
US

V. Phone/Fax

Practice location:
  • Phone: 573-855-9110
  • Fax:
Mailing address:
  • Phone: 573-308-6740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2024003379
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number143444
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: