Provider Demographics
NPI:1437396850
Name:JACK BROWN CENTER
Entity Type:Organization
Organization Name:JACK BROWN CENTER
Other - Org Name:CHEROKEE NATION
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:D
Authorized Official - Last Name:DRY
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:191-845-5520
Mailing Address - Street 1:21141 S FORREST DR
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-7404
Mailing Address - Country:US
Mailing Address - Phone:918-207-0810
Mailing Address - Fax:
Practice Address - Street 1:17091 SOUTH MUSKOGEE AVENUE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74465
Practice Address - Country:US
Practice Address - Phone:918-453-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3261324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility