Provider Demographics
NPI:1013543750
Name:BROWN, JACQUETTE SHINEESE
Entity Type:Individual
Prefix:
First Name:JACQUETTE
Middle Name:SHINEESE
Last Name:BROWN
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 1:20987 N JOHN WAYNE PKWY # B104-113
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85139-2926
Mailing Address - Country:US
Mailing Address - Phone:520-251-1575
Mailing Address - Fax:
Practice Address - Street 1:1845 S DOBSON RD STE 211
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-5663
Practice Address - Country:US
Practice Address - Phone:520-251-1575
Practice Address - Fax:520-635-4758
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-13
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401020212101YP2500X
AZLPC-18852101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty