Healthcare Provider Details

I. General information

NPI: 1700839420
Provider Name (Legal Business Name): JERRY FOWLER LSCW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 PATRICK CREEK DR
MCKINLEYVILLE CA
95519-8024
US

IV. Provider business mailing address

5300 PATRICK CREEK DR
MCKINLEYVILLE CA
95519-8024
US

V. Phone/Fax

Practice location:
  • Phone: 707-839-0123
  • Fax:
Mailing address:
  • Phone: 707-839-0123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number652
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number5750
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: