Provider Demographics
NPI:1992347181
Name:FOWLER, JESSICA LAYNNE (OD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:LAYNNE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4801 S CLIFF AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6954
Mailing Address - Country:US
Mailing Address - Phone:816-350-4536
Mailing Address - Fax:816-350-4585
Practice Address - Street 1:1013 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2181
Practice Address - Country:US
Practice Address - Phone:620-687-4038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023004714152W00000X
CT3148152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2023004714OtherSTATE LICENSE