Healthcare Provider Details

I. General information

NPI: 1134466683
Provider Name (Legal Business Name): JESSICA LYN COWAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2013
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 W 100 S
HURRICANE UT
84737-3229
US

IV. Provider business mailing address

802 W 100 S
HURRICANE UT
84737-3229
US

V. Phone/Fax

Practice location:
  • Phone: 435-319-0889
  • Fax:
Mailing address:
  • Phone: 801-759-8558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number11079157-3502
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11079157
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number165617091
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: