Provider Demographics
NPI:1366811259
Name:GOWAN, JACQUE A (LICSW)
Entity type:Individual
Prefix:
First Name:JACQUE
Middle Name:A
Last Name:GOWAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5420
Mailing Address - Country:US
Mailing Address - Phone:405-271-4311
Mailing Address - Fax:
Practice Address - Street 1:900 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5420
Practice Address - Country:US
Practice Address - Phone:405-271-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNAP15-839104100000X
MN255901041C0700X
WI89641041C0700X
OK201181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker