Healthcare Provider Details

I. General information

NPI: 1679020127
Provider Name (Legal Business Name): JADA BOWER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 MARIGOLD DR. NE
ALBUQUERQUE NM
87122-1112
US

IV. Provider business mailing address

1121 MARIGOLD DR NE
ALBUQUERQUE NM
87122-1112
US

V. Phone/Fax

Practice location:
  • Phone: 505-280-7276
  • Fax:
Mailing address:
  • Phone: 505-280-7276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number286262
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number02734408
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: