Basic Information
| Provider Information | |||||||||
| NPI: | 1134663313 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | IMFT-S, LPCC-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 807 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302414444 | ||||||||
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| Practice Location | |||||||||
| Address1: | 807 E WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302414444 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2016 | ||||||||
| LastUpdateDate: | 01/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | F.1800035-SUPV | OH | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | E.1800520-SUPV | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0260282 | 05 | OH | MEDICAID |