Provider Demographics
NPI:1598787897
Name:BOWEN, JEROD BRADFORD (PT)
Entity Type:Individual
Prefix:
First Name:JEROD
Middle Name:BRADFORD
Last Name:BOWEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S MCCLINTOCK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-4816
Mailing Address - Country:US
Mailing Address - Phone:801-633-6696
Mailing Address - Fax:
Practice Address - Street 1:100 S MCCLINTOCK DR STE 100
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-4816
Practice Address - Country:US
Practice Address - Phone:602-481-7369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ102504Medicare ID - Type Unspecified
AZQ20302Medicare UPIN