Provider Demographics
NPI:1467591289
Name:BROWN, JERRY W (PHD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
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:PO BOX 94508
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-4508
Mailing Address - Country:US
Mailing Address - Phone:505-400-7282
Mailing Address - Fax:
Practice Address - Street 1:6300 RIVERSIDE PLAZA LN NW
Practice Address - Street 2:SUITE 100
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-2617
Practice Address - Country:US
Practice Address - Phone:505-400-7282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2389103TC0700X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCA4166Medicare PIN