Healthcare Provider Details

I. General information

NPI: 1972016970
Provider Name (Legal Business Name): JESSICA BOWDEN CDCA.167835
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2017
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 MARION PIKE STE 1
COAL GROVE OH
45638-2958
US

IV. Provider business mailing address

323 MARION PIKE STE 1
COAL GROVE OH
45638-2958
US

V. Phone/Fax

Practice location:
  • Phone: 740-646-6640
  • Fax: 866-475-7263
Mailing address:
  • Phone: 740-237-4981
  • Fax: 866-325-2816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.002826
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.164368
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: