Provider Demographics
NPI:1558110486
Name:WOMACK, JORDAN DABNEY
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:DABNEY
Last Name:WOMACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2739 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-2556
Mailing Address - Country:US
Mailing Address - Phone:601-862-1126
Mailing Address - Fax:
Practice Address - Street 1:2739 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-2556
Practice Address - Country:US
Practice Address - Phone:601-862-1126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist