Healthcare Provider Details

I. General information

NPI: 1710277520
Provider Name (Legal Business Name): MRS. JACKIE LYNN FOWLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACKIE LYNN YOUNG

II. Dates (important events)

Enumeration Date: 04/13/2011
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12440 E. FIRESTONE BLVD. STE. 1000
NORWALK CA
90650-4448
US

IV. Provider business mailing address

14646 BIOLA AVE
LA MIRADA CA
90638-4448
US

V. Phone/Fax

Practice location:
  • Phone: 562-864-3722
  • Fax: 562-864-4596
Mailing address:
  • Phone: 714-345-3795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: