Basic Information
| Provider Information | |||||||||
| NPI: | 1073835062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ERLENE | ||||||||
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| Credential: | PT,DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2415 IDLEWILDE DR APT 4 | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797076134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4329401390 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 620 N ALLEGHANEY AVE | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797614408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323328244 | ||||||||
| FaxNumber: | 4325807428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2010 | ||||||||
| LastUpdateDate: | 03/11/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1194128 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1194128 | 01 | TX | PT LICENSE | OTHER |