Basic Information
Provider Information | |||||||||
NPI: | 1912658444 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOWEN | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 330 | ||||||||
Address2: |   | ||||||||
City: | MAGNA | ||||||||
State: | UT | ||||||||
PostalCode: | 840440330 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019904300 | ||||||||
FaxNumber: | 8019672127 | ||||||||
Practice Location | |||||||||
Address1: | 50 N MAIN ST | ||||||||
Address2: |   | ||||||||
City: | TOOELE | ||||||||
State: | UT | ||||||||
PostalCode: | 840742139 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8019904300 | ||||||||
FaxNumber: | 8019672127 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2022 | ||||||||
LastUpdateDate: | 01/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.