Provider Demographics
NPI:1538618145
Name:WILLIAMS, JERRY (FNP-BC)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 BROAD AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2404
Mailing Address - Country:US
Mailing Address - Phone:228-575-2700
Mailing Address - Fax:228-575-2710
Practice Address - Street 1:1340 BROAD AVE STE 300
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2404
Practice Address - Country:US
Practice Address - Phone:228-575-2700
Practice Address - Fax:228-575-2710
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000021599363LF0000X
MS903695363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily