Provider Demographics
NPI:1164424164
Name:BROWN, JACKLYNN V (RPA-C)
Entity Type:Individual
Prefix:
First Name:JACKLYNN
Middle Name:V
Last Name:BROWN
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 REARDON RD
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12804-8608
Mailing Address - Country:US
Mailing Address - Phone:518-793-3703
Mailing Address - Fax:518-654-7695
Practice Address - Street 1:200 SMITH DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:NY
Practice Address - Zip Code:12822-1341
Practice Address - Country:US
Practice Address - Phone:518-654-7680
Practice Address - Fax:518-654-7695
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004699363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS68799Medicare UPIN
NYPA0409Medicare ID - Type Unspecified