Healthcare Provider Details

I. General information

NPI: 1740581222
Provider Name (Legal Business Name): JAQUANE WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 04/28/2024
Certification Date: 04/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2125 FREMONT DR
THE VILLAGE OK
73120-3802
US

IV. Provider business mailing address

2125 FREMONT DR
THE VILLAGE OK
73120-3802
US

V. Phone/Fax

Practice location:
  • Phone: 405-409-5692
  • Fax:
Mailing address:
  • Phone: 405-409-5692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: