MEDICARE: JAHSMINE FOWLER

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	106S00000X	Behavior Technician		NC

General Provider Information

NPI Number	:	1578323226
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAHSMINE FOWLER

Provider Business Mailing Address
First Line	:	8311 BRIER CREEK PKWY STE 105-501
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27617-7328
Country	:	US
Telephone Number	:	336-560-7878
Fax Number	:	336-560-7878

Provider Business Practice Location Address
First Line	:	8530 CLIFF CAMERON DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-5906
Country	:	US
Telephone Number	:	336-560-7878
Fax Number	:

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

Provider Enumeration Date	:	03/20/2024
Last Update Date	:	06/14/2024

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