Healthcare Provider Details

I. General information

NPI: 1609426352
Provider Name (Legal Business Name): JESSICA BOWDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2019
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 PARK AVE STE 200
ORANGE PARK FL
32073-5571
US

IV. Provider business mailing address

2300 PARK AVE
ORANGE PARK FL
32073-5571
US

V. Phone/Fax

Practice location:
  • Phone: 904-308-3751
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY9992
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY004197
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: