Healthcare Provider Details

I. General information

NPI: 1316678659
Provider Name (Legal Business Name): INDIANA JASON WOMACK B.A., CMPSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 FULTON AVE STE 205
SACRAMENTO CA
95825-4517
US

IV. Provider business mailing address

7484 HOLWORTHY WAY APT 84
SACRAMENTO CA
95842-4131
US

V. Phone/Fax

Practice location:
  • Phone: 916-484-3570
  • Fax:
Mailing address:
  • Phone: 731-441-9554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-CYUFDS
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: