Healthcare Provider Details

I. General information

NPI: 1063081578
Provider Name (Legal Business Name): JERRY WILLIAMS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2021
Last Update Date: 06/19/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 CADY ST
ROCHESTER NY
14608-2324
US

IV. Provider business mailing address

106 CADY ST
ROCHESTER NY
14608-2324
US

V. Phone/Fax

Practice location:
  • Phone: 585-512-7320
  • Fax:
Mailing address:
  • Phone: 585-512-7320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: