Healthcare Provider Details

I. General information

NPI: 1740438134
Provider Name (Legal Business Name): JONATHAN MATTHEW BOWEN M.ED, LCPC-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 SUMMER ST
BANGOR ME
04401-6446
US

IV. Provider business mailing address

311 MEMORIAL UN
ORONO ME
04469-0001
US

V. Phone/Fax

Practice location:
  • Phone: 207-945-4240
  • Fax:
Mailing address:
  • Phone: 207-949-6768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberXL3400
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberXL3400
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: