Healthcare Provider Details

I. General information

NPI: 1235530601
Provider Name (Legal Business Name): MR. JERRY JOE LOWDEN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3491 GANDY BLVD N STE 201
PINELLAS PARK FL
33781-2654
US

IV. Provider business mailing address

3491 GANDY BLVD N STE 201
PINELLAS PARK FL
33781-2654
US

V. Phone/Fax

Practice location:
  • Phone: 912-622-3457
  • Fax:
Mailing address:
  • Phone: 912-622-3457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: