Basic Information
| Provider Information | |||||||||
| NPI: | 1760899199 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOWLIN-JOHNSON | ||||||||
| FirstName: | JO | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | BOWLIN | ||||||||
| OtherFirstName: | JO | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 350 | ||||||||
| Address2: | |||||||||
| City: | MAPLE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980380350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253580956 | ||||||||
| FaxNumber: | 8774816931 | ||||||||
| Practice Location | |||||||||
| Address1: | 11516 SE MILL PLAIN BLVD | ||||||||
| Address2: | STE. J-2 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986845005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608828027 | ||||||||
| FaxNumber: | 3608828030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2014 | ||||||||
| LastUpdateDate: | 08/26/2016 | ||||||||
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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 | 237600000X | LD 60155983 | WA | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237600000X | 30790 | OR | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 2038850 | 05 | WA | MEDICAID | 500675781 | 05 | OR | MEDICAID |