Provider Demographics
NPI:1730163478
Name:BROWN, JEFFREY (MA LP)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 LILAC DRIVE N
Mailing Address - Street 2:STE 130
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4536
Mailing Address - Country:US
Mailing Address - Phone:763-566-0922
Mailing Address - Fax:763-503-9194
Practice Address - Street 1:1405 LILAC DR N
Practice Address - Street 2:STE 130
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4536
Practice Address - Country:US
Practice Address - Phone:763-566-0922
Practice Address - Fax:763-503-9491
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 2069103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN663282300Medicaid