Provider Demographics
NPI:1285648170
Name:BROWN, CHARLES JACOB (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JACOB
Last Name:BROWN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5114
Mailing Address - Country:US
Mailing Address - Phone:704-376-8494
Mailing Address - Fax:
Practice Address - Street 1:726 EAST BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5114
Practice Address - Country:US
Practice Address - Phone:704-376-8494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1981174400000X
NCPP1981103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD123456OtherNOT APPLICABLE