Provider Demographics
NPI:1093180549
Name:MCGOWAN, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:MCGOWAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 9TH STREET, APT. 3
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:781-603-5256
Mailing Address - Fax:
Practice Address - Street 1:932 9TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-2861
Practice Address - Country:US
Practice Address - Phone:781-603-5256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1-11-8949103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst