Provider Demographics
NPI:1245903509
Name:WILLIAMS, JEREMEY EDWARD
Entity type:Individual
Prefix:MR
First Name:JEREMEY
Middle Name:EDWARD
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 S CURLEY ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-3849
Mailing Address - Country:US
Mailing Address - Phone:917-257-8940
Mailing Address - Fax:
Practice Address - Street 1:1105 HOLLEN RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-1715
Practice Address - Country:US
Practice Address - Phone:917-257-8940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-31
Last Update Date:2021-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD30AL3907310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility