Provider Demographics
NPI:1912429465
Name:BOWDEN, JEREMY PAUL
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:PAUL
Last Name:BOWDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 PEPPERTREE LN APT D
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3850
Mailing Address - Country:US
Mailing Address - Phone:949-254-1344
Mailing Address - Fax:
Practice Address - Street 1:1115 W BALBOA BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92661-1037
Practice Address - Country:US
Practice Address - Phone:949-675-3764
Practice Address - Fax:949-675-5797
Is Sole Proprietor?:No
Enumeration Date:2017-07-15
Last Update Date:2017-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician