Provider Demographics
NPI:1205368578
Name:BOWEN, JACQUELYN
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:
Last Name:BOWEN
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 1:2306 PLYMOUTH COLONY
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-8742
Mailing Address - Country:US
Mailing Address - Phone:214-263-3411
Mailing Address - Fax:
Practice Address - Street 1:2306 PLYMOUTH COLONY DR
Practice Address - Street 2:
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078-8742
Practice Address - Country:US
Practice Address - Phone:214-263-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX198221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical