Healthcare Provider Details

I. General information

NPI: 1750917720
Provider Name (Legal Business Name): JEROME ANTHONY BOWERS PRACTICUM CLINICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2020
Last Update Date: 03/20/2020
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14275 MIDWAY RD STE 260
ADDISON TX
75001-3613
US

IV. Provider business mailing address

14275 MIDWAY RD STE 260
ADDISON TX
75001-3613
US

V. Phone/Fax

Practice location:
  • Phone: 856-912-8928
  • Fax: 855-437-2354
Mailing address:
  • Phone: 856-912-8928
  • Fax: 855-437-2354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: