Healthcare Provider Details

I. General information

NPI: 1326190562
Provider Name (Legal Business Name): JODEE JEAN BOWER LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N KENTUCKY AVE
ROSWELL NM
88201-4636
US

IV. Provider business mailing address

1102 N LEA AVE
ROSWELL NM
88201-5033
US

V. Phone/Fax

Practice location:
  • Phone: 505-627-2562
  • Fax: 505-627-2544
Mailing address:
  • Phone: 505-627-2562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberI-04853
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: