Basic Information
| Provider Information | |||||||||
| NPI: | 1366772410 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOMMACK | ||||||||
| FirstName: | JEROLINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCLS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751177 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282135253 | ||||||||
| FaxNumber: | 8282135265 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 BILTMORE AVE | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288014601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282135253 | ||||||||
| FaxNumber: | 8282135265 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2010 | ||||||||
| LastUpdateDate: | 01/12/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C002994 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.