Provider Demographics
NPI:1710277520
Name:FOWLER, JACKIE LYNN
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:LYNN
Last Name:FOWLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:LYNN
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14646 BIOLA AVE
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-4448
Mailing Address - Country:US
Mailing Address - Phone:714-345-3795
Mailing Address - Fax:
Practice Address - Street 1:12440 E. FIRESTONE BLVD.
Practice Address - Street 2:STE. 1000
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-4448
Practice Address - Country:US
Practice Address - Phone:562-864-3722
Practice Address - Fax:562-864-4596
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor