Provider Demographics
NPI:1114416393
Name:BOWENS, JENNIFER (CERTIFIED HAIR LOSS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BOWENS
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 COMMERCIAL HTS STE A
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-3395
Mailing Address - Country:US
Mailing Address - Phone:478-225-3584
Mailing Address - Fax:
Practice Address - Street 1:112 COMMERCIAL HTS STE A
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-3395
Practice Address - Country:US
Practice Address - Phone:478-225-3584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO1241851744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management