Provider Demographics
NPI:1265204440
Name:GANSON-BOWMAN, JENNIFER LEE
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEE
Last Name:GANSON-BOWMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9875 SNAPPTOWN RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:OH
Mailing Address - Zip Code:43343-9520
Mailing Address - Country:US
Mailing Address - Phone:193-772-6805
Mailing Address - Fax:
Practice Address - Street 1:124 W APPLE ST STE 3
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-2617
Practice Address - Country:US
Practice Address - Phone:193-772-6805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH109633146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic