Provider Demographics
NPI:1033185475
Name:WOMACK, MARTHA B (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:B
Last Name:WOMACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 N JEFFERSON ST
Mailing Address - Street 2:JACKSONVILLE OUTPATIENT CLINIC
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6525
Mailing Address - Country:US
Mailing Address - Phone:912-447-5660
Mailing Address - Fax:
Practice Address - Street 1:1536 N JEFFERSON ST
Practice Address - Street 2:JACKSONVILLE OUTPATIENT CLINIC
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6525
Practice Address - Country:US
Practice Address - Phone:912-447-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-26
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1624103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000841574AMedicaid
GA68BBCXQMedicare ID - Type Unspecified