MEDICARE: DR. JENNIFER FOWLER PSYD

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	103T00000X	Psychologist
2	103TC0700X	Clinical Psychologist	PSY-005217	AZ

General Provider Information

NPI Number	:	1295135432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER FOWLER PSYD

Provider Business Mailing Address
First Line	:	2400 W DUNLAP AVE STE 124
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85021-2813
Country	:	US
Telephone Number	:	801-369-8989
Fax Number	:	801-704-9741

Provider Business Practice Location Address
First Line	:	2400 W DUNLAP AVE STE 124
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85021-2813
Country	:	US
Telephone Number	:	801-369-8989
Fax Number	:	801-704-9741

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

Provider Enumeration Date	:	08/25/2014
Last Update Date	:	02/21/2023

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