Provider Demographics
NPI:1154070894
Name:FOWLER, JIM WAYNE (LPC)
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:WAYNE
Last Name:FOWLER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CARRIAGE DR
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-6502
Mailing Address - Country:US
Mailing Address - Phone:214-912-9538
Mailing Address - Fax:
Practice Address - Street 1:101 CARRIAGE DR
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-6502
Practice Address - Country:US
Practice Address - Phone:214-912-9538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6944101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional