Provider Demographics
NPI:1710465265
Name:MCGOWIN, JACOB PETER BROWN
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:PETER BROWN
Last Name:MCGOWIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 BELLEVUE AVE APT 205
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-3940
Mailing Address - Country:US
Mailing Address - Phone:818-749-8288
Mailing Address - Fax:
Practice Address - Street 1:360 S WESTLAKE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-2906
Practice Address - Country:US
Practice Address - Phone:213-483-9201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACI35570422101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1311470618Medicaid