Provider Demographics
NPI:1235530601
Name:LOWDEN, JERRY JOE JR
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:JOE
Last Name:LOWDEN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3491 GANDY BLVD N STE 201
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-2654
Mailing Address - Country:US
Mailing Address - Phone:912-622-3457
Mailing Address - Fax:
Practice Address - Street 1:3491 GANDY BLVD N STE 201
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-2654
Practice Address - Country:US
Practice Address - Phone:912-622-3457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-04
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
GAAPC 0004232101YM0800X, 167G00000X
APC 004232101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAAPC 00004232OtherGEORGIA LICENSING BOARD