Provider Demographics
NPI:1114041423
Name:LOWELL, JESSIE ROSE (PSYD)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:ROSE
Last Name:LOWELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 N SAN DIMAS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1223
Mailing Address - Country:US
Mailing Address - Phone:909-519-8732
Mailing Address - Fax:
Practice Address - Street 1:1270 N SAN DIMAS CANYON RD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1223
Practice Address - Country:US
Practice Address - Phone:909-519-8732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23333103TC0700X, 103TC2200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program