Healthcare Provider Details

I. General information

NPI: 1922298975
Provider Name (Legal Business Name): JACKIE L WILLIAMS MS, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 SOUTH COMMERCE
ARDMORE OK
73401
US

IV. Provider business mailing address

PO BOX 189
ARDMORE OK
73402-0189
US

V. Phone/Fax

Practice location:
  • Phone: 580-223-5070
  • Fax: 580-223-5617
Mailing address:
  • Phone: 580-223-5070
  • Fax: 580-223-5617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number578
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: