Provider Demographics
NPI:1558081331
Name:FOWLER, JADEN IVORY (BSN RN CCRN)
Entity Type:Individual
Prefix:
First Name:JADEN
Middle Name:IVORY
Last Name:FOWLER
Suffix:
Gender:M
Credentials:BSN RN CCRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43117 CHAUCER CT
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1830
Mailing Address - Country:US
Mailing Address - Phone:248-514-0320
Mailing Address - Fax:
Practice Address - Street 1:43117 CHAUCER CT
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1830
Practice Address - Country:US
Practice Address - Phone:248-514-0320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704338945163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse