Provider Demographics
NPI:1073835062
Name:FOWLER, JENNIFER ERLENE (PT,DPT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ERLENE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 IDLEWILDE DR APT 4
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-6134
Mailing Address - Country:US
Mailing Address - Phone:432-940-1390
Mailing Address - Fax:
Practice Address - Street 1:620 N ALLEGHANEY AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4408
Practice Address - Country:US
Practice Address - Phone:432-332-8244
Practice Address - Fax:432-580-7428
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1194128225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1194128OtherPT LICENSE