Healthcare Provider Details

I. General information

NPI: 1679127062
Provider Name (Legal Business Name): JEFFREY WADE WOMACK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 CHICKESAW ST
SENECA MO
64865-9281
US

IV. Provider business mailing address

1623 KINGSBURY AVE
MIAMI OK
74354-2180
US

V. Phone/Fax

Practice location:
  • Phone: 417-776-8041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2018007364
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2513
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: