Healthcare Provider Details

I. General information

NPI: 1164347076
Provider Name (Legal Business Name): JENNIFER OWEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 29TH AVENUE DRIVE NE
HIC NC
28601
US

IV. Provider business mailing address

1824 TOUBY PIKE STE B
KOKOMO IN
46901-2573
US

V. Phone/Fax

Practice location:
  • Phone: 574-387-4313
  • Fax: 574-204-2868
Mailing address:
  • Phone: 574-387-4313
  • Fax: 574-204-2868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-546510
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: