Provider Demographics
NPI:1902298029
Name:COWEN, JENA
Entity Type:Individual
Prefix:
First Name:JENA
Middle Name:
Last Name:COWEN
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:PO BOX 3365
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82717-3365
Mailing Address - Country:US
Mailing Address - Phone:307-299-0567
Mailing Address - Fax:
Practice Address - Street 1:5305 COWEN DRIVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718
Practice Address - Country:US
Practice Address - Phone:307-299-0567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-26
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X
WY251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY82-2756226Medicaid