Healthcare Provider Details

I. General information

NPI: 1063230688
Provider Name (Legal Business Name): JACOB COWAN PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8350 STATE ROUTE 30
DITTMER MO
63023-1909
US

IV. Provider business mailing address

1687 E BUENA VISTA ST
SPRINGFIELD MO
65804-4359
US

V. Phone/Fax

Practice location:
  • Phone: 636-707-2097
  • Fax:
Mailing address:
  • Phone: 417-631-9444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2024028653
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: