Provider Demographics
NPI:1306182035
Name:BOWEN, JASON RANDEL (FNP)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:RANDEL
Last Name:BOWEN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 333
Mailing Address - Street 2:
Mailing Address - City:HARRISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39082-0333
Mailing Address - Country:US
Mailing Address - Phone:601-847-2224
Mailing Address - Fax:601-847-2199
Practice Address - Street 1:1827C SIMPSON HIGHWAY 149
Practice Address - Street 2:
Practice Address - City:MENDENHALL
Practice Address - State:MS
Practice Address - Zip Code:39114-3439
Practice Address - Country:US
Practice Address - Phone:601-847-2224
Practice Address - Fax:601-847-2199
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR861662363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner