Provider Demographics
NPI:1073678843
Name:BROWN, JACK SCOTT (PHD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:SCOTT
Last Name:BROWN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10801 W 87TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66214
Mailing Address - Country:US
Mailing Address - Phone:913-438-2100
Mailing Address - Fax:913-438-2119
Practice Address - Street 1:10801 W 87TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66214
Practice Address - Country:US
Practice Address - Phone:913-438-2100
Practice Address - Fax:913-438-2119
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSKSLP0973103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
25156039OtherBLUE CROSS BLUE SHIELD