Provider Demographics
NPI:1689043390
Name:FOWLER, JESSICA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4242 MEDICAL DR
Mailing Address - Street 2:STE 6150
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-5369
Mailing Address - Country:US
Mailing Address - Phone:210-342-1906
Mailing Address - Fax:210-634-2292
Practice Address - Street 1:4242 MEDICAL DR
Practice Address - Street 2:STE 6150
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5369
Practice Address - Country:US
Practice Address - Phone:210-342-1906
Practice Address - Fax:210-634-2292
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37149103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist