Provider Demographics
NPI:1366772410
Name:WOMMACK, JEROLINE (LCLS)
Entity type:Individual
Prefix:
First Name:JEROLINE
Middle Name:
Last Name:WOMMACK
Suffix:
Gender:F
Credentials:LCLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751177
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1177
Mailing Address - Country:US
Mailing Address - Phone:828-213-5253
Mailing Address - Fax:828-213-5265
Practice Address - Street 1:509 BILTMORE AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4601
Practice Address - Country:US
Practice Address - Phone:828-213-5253
Practice Address - Fax:828-213-5265
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0029941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical