Basic Information
| Provider Information | |||||||||
| NPI: | 1134395197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOWRER | ||||||||
| FirstName: | JACKIE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUNN | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 515 BAYOU ST | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475911034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128866800 | ||||||||
| FaxNumber: | 8128866809 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 BUNTIN ST | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475911320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128852700 | ||||||||
| FaxNumber: | 8128852716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2008 | ||||||||
| LastUpdateDate: | 07/01/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34005752A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.