Provider Demographics
NPI:1548630650
Name:BROWN, JESSIE
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:BROWN
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 1:8204 NW 31ST TER
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-4348
Mailing Address - Country:US
Mailing Address - Phone:580-458-0920
Mailing Address - Fax:
Practice Address - Street 1:8204 NW 31ST TER
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-4348
Practice Address - Country:US
Practice Address - Phone:580-458-0920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health