Provider Demographics
NPI:1700839420
Name:FOWLER, JERRY (LSCW)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:
Last Name:FOWLER
Suffix:
Gender:M
Credentials:LSCW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 PATRICK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-8024
Mailing Address - Country:US
Mailing Address - Phone:707-839-0123
Mailing Address - Fax:
Practice Address - Street 1:5300 PATRICK CREEK DR
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-8024
Practice Address - Country:US
Practice Address - Phone:707-839-0123
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6521041C0700X
CA5750106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ36142ZMedicare ID - Type Unspecified