Provider Demographics
NPI:1316220593
Name:FOWLER, JEREMIAH JERELL
Entity type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:JERELL
Last Name:FOWLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 ELM ST SW
Mailing Address - Street 2:
Mailing Address - City:POULAN
Mailing Address - State:GA
Mailing Address - Zip Code:31781-3736
Mailing Address - Country:US
Mailing Address - Phone:229-296-7907
Mailing Address - Fax:
Practice Address - Street 1:418 ELM ST SW
Practice Address - Street 2:
Practice Address - City:POULAN
Practice Address - State:GA
Practice Address - Zip Code:31781-3736
Practice Address - Country:US
Practice Address - Phone:229-296-7907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002755225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant