Provider Demographics
NPI:1053582445
Name:FOWLER, JACQUELINE BERNICE (HAPP, LMT)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:BERNICE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:HAPP, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8620 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46403-1423
Mailing Address - Country:US
Mailing Address - Phone:219-963-2956
Mailing Address - Fax:
Practice Address - Street 1:8620 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46403-1423
Practice Address - Country:US
Practice Address - Phone:219-963-2956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TP2701X, 173C00000X, 175F00000X
IN00000171100000X
IN172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No171100000XOther Service ProvidersAcupuncturist
No173C00000XOther Service ProvidersReflexologist
No175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
INMT209011898OtherLICENSED MASSAGE THERAPIST/ MECHANO THERAPIST
IN00000OtherHOLISTIC ALTERNATIVE PSYCHOLOGY PRACTITIONER