Provider Demographics
NPI:1114770658
Name:BROWN, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W WASHINGTON AVE STE 280
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-1074
Mailing Address - Country:US
Mailing Address - Phone:616-259-5452
Mailing Address - Fax:616-236-0875
Practice Address - Street 1:201 W WASHINGTON AVE STE 280
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1074
Practice Address - Country:US
Practice Address - Phone:616-259-5452
Practice Address - Fax:616-236-0875
Is Sole Proprietor?:No
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009526103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral