Basic Information
| Provider Information | |||||||||
| NPI: | 1710277520 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | JACKIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | YOUNG | ||||||||
| OtherFirstName: | JACKIE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 14646 BIOLA AVE | ||||||||
| Address2: | |||||||||
| City: | LA MIRADA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906384448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143453795 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12440 E. FIRESTONE BLVD. | ||||||||
| Address2: | STE. 1000 | ||||||||
| City: | NORWALK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906504448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628643722 | ||||||||
| FaxNumber: | 5628644596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2011 | ||||||||
| LastUpdateDate: | 05/26/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.