Provider Demographics
NPI:1053874685
Name:WOMACK, JACQUELINE (LMFT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WOMACK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7955 DRUMMER CIR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8088
Mailing Address - Country:US
Mailing Address - Phone:979-218-5879
Mailing Address - Fax:
Practice Address - Street 1:207 ROCK PRAIRIE RD STE B
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8777
Practice Address - Country:US
Practice Address - Phone:979-229-7636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202349106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist