Provider Demographics
NPI:1902156755
Name:WOON, MARTIN (PHD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:WOON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:257 BANCORP SOUTH PKWY
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-7582
Mailing Address - Country:US
Mailing Address - Phone:731-512-1283
Mailing Address - Fax:731-660-8739
Practice Address - Street 1:700 W FOREST AVE STE 200
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3940
Practice Address - Country:US
Practice Address - Phone:731-541-9490
Practice Address - Fax:731-541-9486
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36320103G00000X, 103T00000X
TN3982103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ086560Medicaid
TX306366102Medicaid