Healthcare Provider Details

I. General information

NPI: 1700594819
Provider Name (Legal Business Name): JONATHAN MARK BOWERS PRS, QMHS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 BOARDMAN CANFIELD RD STE C4
YOUNGSTOWN OH
44512-4367
US

IV. Provider business mailing address

725 BOARDMAN CANFIELD RD STE C4
YOUNGSTOWN OH
44512-4367
US

V. Phone/Fax

Practice location:
  • Phone: 855-292-9778
  • Fax:
Mailing address:
  • Phone: 855-292-9778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.003648
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: