Provider Demographics
NPI:1922510791
Name:BOWMAN, JESSICA MARIE (LLP, CIC-CPP, C-DBT)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:BOWMAN
Suffix:
Gender:F
Credentials:LLP, CIC-CPP, C-DBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 E ELM AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2684
Mailing Address - Country:US
Mailing Address - Phone:313-778-3489
Mailing Address - Fax:
Practice Address - Street 1:1 PARKLANE BLVD STE E200
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2400
Practice Address - Country:US
Practice Address - Phone:313-846-2606
Practice Address - Fax:313-846-2657
Is Sole Proprietor?:No
Enumeration Date:2017-11-01
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361008001103TB0200X, 103TC2200X, 103TH0004X, 103TM1800X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities