Healthcare Provider Details

I. General information

NPI: 1174934533
Provider Name (Legal Business Name): JESSICA WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3304 E I 80 SERVICE RD
CHEYENNE WY
82009-8781
US

IV. Provider business mailing address

2109 E 13TH ST
CHEYENNE WY
82001-5103
US

V. Phone/Fax

Practice location:
  • Phone: 307-829-7355
  • Fax:
Mailing address:
  • Phone: 307-259-0017
  • 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: