Provider Demographics
NPI:1104476357
Name:OWENS, JENNIFER DAWN
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:DAWN
Last Name:OWENS
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 1:315 TANGLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-1130
Mailing Address - Country:US
Mailing Address - Phone:440-668-5342
Mailing Address - Fax:440-291-8025
Practice Address - Street 1:315 TANGLEWOOD LN
Practice Address - Street 2:
Practice Address - City:BAY VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44140-1130
Practice Address - Country:US
Practice Address - Phone:440-291-8025
Practice Address - Fax:440-291-8025
Is Sole Proprietor?:No
Enumeration Date:2019-09-18
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-23-263069106S00000X
ILRBT-19-99252106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician