Provider Demographics
NPI:1093459364
Name:BROWN, JACK HARRISON (DPT)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:HARRISON
Last Name:BROWN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2113 TENNYSON CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-6663
Mailing Address - Country:US
Mailing Address - Phone:757-401-2352
Mailing Address - Fax:
Practice Address - Street 1:2247 W GREAT NECK RD STE 101
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-1556
Practice Address - Country:US
Practice Address - Phone:757-742-3778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-23
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052148682251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic