MEDICARE: JESSICA FOWLER IMFT-S, LPCC-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	F.1800035-SUPV	OH
2	101YM0800X	Mental Health Counselor	E.1800520-SUPV	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134663313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA FOWLER IMFT-S, LPCC-S

Provider Business Mailing Address
First Line	:	807 E WASHINGTON ST
Second Line	:
City	:	MEDINA
State	:	OH
Zip	:	44256-3338
Country	:	US
Telephone Number	:	330-241-4444
Fax Number	:

Provider Business Practice Location Address
First Line	:	807 E WASHINGTON ST
Second Line	:
City	:	MEDINA
State	:	OH
Zip	:	44256-3338
Country	:	US
Telephone Number	:	330-241-4444
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2016
Last Update Date	:	01/23/2020

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