Provider Demographics
NPI:1114411923
Name:BROWN, JOHN JAY JR (MSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JAY
Last Name:BROWN
Suffix:JR
Gender:M
Credentials:MSW
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:JAY
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:4016 GRAND MANOR CT APT 302
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-7819
Mailing Address - Country:US
Mailing Address - Phone:716-954-6118
Mailing Address - Fax:
Practice Address - Street 1:8382 SIX FORKS RD STE 103
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5080
Practice Address - Country:US
Practice Address - Phone:919-720-5196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC$$$$$$$$$Medicaid