Provider Demographics
NPI:1275964066
Name:BROWN, JERROLD (LPC)
Entity Type:Individual
Prefix:
First Name:JERROLD
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1736 1 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MI
Mailing Address - Zip Code:49052-9612
Mailing Address - Country:US
Mailing Address - Phone:269-729-5292
Mailing Address - Fax:
Practice Address - Street 1:1736 1 MILE RD
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MI
Practice Address - Zip Code:49052-9612
Practice Address - Country:US
Practice Address - Phone:269-729-5292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011317101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor