Provider Demographics
NPI:1760713812
Name:SURJUE-BOWENS, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SURJUE-BOWENS
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 1:901 N PCH HWY # 200A204A
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2162
Mailing Address - Country:US
Mailing Address - Phone:310-316-1600
Mailing Address - Fax:310-316-4200
Practice Address - Street 1:901 N PCH HWY STE 200A204A
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2162
Practice Address - Country:US
Practice Address - Phone:310-316-1600
Practice Address - Fax:310-316-4200
Is Sole Proprietor?:No
Enumeration Date:2010-01-28
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XOtherMEDICAL