Provider Demographics
NPI:1275289456
Name:BROWN, JACK
Entity Type:Individual
Prefix:
First Name:JACK
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 1:1130 N NIMITZ HWY
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-4579
Mailing Address - Country:US
Mailing Address - Phone:718-791-3460
Mailing Address - Fax:
Practice Address - Street 1:1130 N NIMITZ HWY
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-4579
Practice Address - Country:US
Practice Address - Phone:718-791-3460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator