Healthcare Provider Details

I. General information

NPI: 1003130766
Provider Name (Legal Business Name): NIA JOWAN GRANT LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2010
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4530 MONTAIR AVE APT 15
LONG BEACH CA
90808-1229
US

IV. Provider business mailing address

PO BOX 8053
INGLEWOOD CA
90308-8053
US

V. Phone/Fax

Practice location:
  • Phone: 678-488-7539
  • Fax:
Mailing address:
  • Phone: 678-488-7539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9213
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number17495
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC005539
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: