Provider Demographics
NPI:1407370778
Name:MCGOWAN, JERMAINE
Entity Type:Individual
Prefix:MR
First Name:JERMAINE
Middle Name:
Last Name:MCGOWAN
Suffix:
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 1:107 ATKINSON ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608-2202
Mailing Address - Country:US
Mailing Address - Phone:585-464-8726
Mailing Address - Fax:
Practice Address - Street 1:107 ATKINSON ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14608-2202
Practice Address - Country:US
Practice Address - Phone:585-464-8726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY821079946172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver