Provider Demographics
NPI:1174213854
Name:FOWLER, JIMMY TONEY
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:TONEY
Last Name:FOWLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 4TH ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44704-2116
Mailing Address - Country:US
Mailing Address - Phone:330-546-8087
Mailing Address - Fax:
Practice Address - Street 1:2204 4TH ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44704-2116
Practice Address - Country:US
Practice Address - Phone:330-546-8087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral