Provider Demographics
NPI:1760043707
Name:HACKER, KOWAN
Entity Type:Individual
Prefix:
First Name:KOWAN
Middle Name:
Last Name:HACKER
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 1:1750 NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5700
Mailing Address - Country:US
Mailing Address - Phone:541-956-4943
Mailing Address - Fax:541-295-3085
Practice Address - Street 1:2020 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2041
Practice Address - Country:US
Practice Address - Phone:541-267-3511
Practice Address - Fax:541-267-3512
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor