Healthcare Provider Details

I. General information

NPI: 1982518007
Provider Name (Legal Business Name): JACK BOWEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23309 N 17TH DR
PHOENIX AZ
85027-6305
US

IV. Provider business mailing address

23309 N 17TH DR STE 100
PHOENIX AZ
85027-6306
US

V. Phone/Fax

Practice location:
  • Phone: 602-641-2464
  • Fax:
Mailing address:
  • Phone: 602-641-2464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-407532
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: