Provider Demographics
NPI:1871845040
Name:WOMBLE, JESSICA MARIE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:WOMBLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 SUBURBAN DR
Mailing Address - Street 2:
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-4085
Mailing Address - Country:US
Mailing Address - Phone:706-669-9111
Mailing Address - Fax:
Practice Address - Street 1:271 SUBURBAN DR
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-4085
Practice Address - Country:US
Practice Address - Phone:706-669-9111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-11
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA343900000X
GA050557322172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)