Provider Demographics
NPI:1679020127
Name:BOWER, JADA
Entity Type:Individual
Prefix:
First Name:JADA
Middle Name:
Last Name:BOWER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 MARIGOLD DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-1112
Mailing Address - Country:US
Mailing Address - Phone:505-280-7276
Mailing Address - Fax:
Practice Address - Street 1:1121 MARIGOLD DR. NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-1112
Practice Address - Country:US
Practice Address - Phone:505-280-7276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM286262251S00000X
TX02734408252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency