Provider Demographics
NPI:1063230688
Name:COWAN, JACOB (PMHNP)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:COWAN
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1687 E BUENA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-4359
Mailing Address - Country:US
Mailing Address - Phone:417-631-9444
Mailing Address - Fax:
Practice Address - Street 1:8350 STATE ROUTE 30
Practice Address - Street 2:
Practice Address - City:DITTMER
Practice Address - State:MO
Practice Address - Zip Code:63023-1909
Practice Address - Country:US
Practice Address - Phone:636-707-2097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024028653363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health