Provider Demographics
NPI:1134663313
Name:FOWLER, JESSICA (IMFT-S, LPCC-S)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:IMFT-S, LPCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3338
Mailing Address - Country:US
Mailing Address - Phone:330-241-4444
Mailing Address - Fax:
Practice Address - Street 1:807 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3338
Practice Address - Country:US
Practice Address - Phone:330-241-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF.1800035-SUPV106H00000X
OHE.1800520-SUPV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0260282Medicaid