Healthcare Provider Details

I. General information

NPI: 1306182035
Provider Name (Legal Business Name): JASON RANDEL BOWEN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2012
Last Update Date: 12/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1827C SIMPSON HIGHWAY 149
MENDENHALL MS
39114-3439
US

IV. Provider business mailing address

PO BOX 333
HARRISVILLE MS
39082-0333
US

V. Phone/Fax

Practice location:
  • Phone: 601-847-2224
  • Fax: 601-847-2199
Mailing address:
  • Phone: 601-847-2224
  • Fax: 601-847-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR861662
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: