Provider Demographics
NPI:1023633625
Name:MCCOWN, JESSE (CDCA178365)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:MCCOWN
Suffix:
Gender:M
Credentials:CDCA178365
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-1403
Mailing Address - Country:US
Mailing Address - Phone:740-237-4981
Mailing Address - Fax:
Practice Address - Street 1:117 N 4TH ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-1403
Practice Address - Country:US
Practice Address - Phone:740-237-4981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH173794101YA0400X
101YM0800X, 171M00000X
OHCDCA.178365101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0406281Medicaid