=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063695443
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA D BOWERS LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2007
-----------------------------------------------------
Last Update Date | 10/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1425 S US 301
-----------------------------------------------------
City | SUMTERVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33585-5141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-793-5900
-----------------------------------------------------
Fax | 352-793-6269
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1243 FLAMINGO PL
-----------------------------------------------------
City | THE VILLAGES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32162-1754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-661-5967
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW6351 (LCSW)
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------