Provider Demographics
NPI:1760822027
Name:FOWLER, JOHNATHAN L (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHNATHAN
Middle Name:L
Last Name:FOWLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2237 RIDGE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-5164
Mailing Address - Country:US
Mailing Address - Phone:972-771-3969
Mailing Address - Fax:972-771-8258
Practice Address - Street 1:2237 RIDGE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-5164
Practice Address - Country:US
Practice Address - Phone:972-771-3969
Practice Address - Fax:972-771-8258
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1262103T00000X
TX36720103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist