Provider Demographics
NPI:1336992940
Name:FOWLER, JESSICA (CASAC-T)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-4116
Mailing Address - Country:US
Mailing Address - Phone:315-218-6492
Mailing Address - Fax:315-214-5764
Practice Address - Street 1:168 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13204-4116
Practice Address - Country:US
Practice Address - Phone:315-218-6492
Practice Address - Fax:315-214-5764
Is Sole Proprietor?:No
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY39005171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator