Provider Demographics
NPI:1245425230
Name:BROWN, JACOB THEODORE JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:THEODORE
Last Name:BROWN
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:THEODORE
Other - Last Name:BROWN
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:7950 CROSSROADS DR
Mailing Address - Street 2:607
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9411
Mailing Address - Country:US
Mailing Address - Phone:843-576-4254
Mailing Address - Fax:800-479-2209
Practice Address - Street 1:7950 CROSSROADS DR
Practice Address - Street 2:607
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9411
Practice Address - Country:US
Practice Address - Phone:843-576-4254
Practice Address - Fax:800-479-2209
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1006103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical