Provider Demographics
NPI:1508426958
Name:BROWN, JONATHAN (PHD, MFT)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:PHD, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 MILLER AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-2851
Mailing Address - Country:US
Mailing Address - Phone:415-383-2990
Mailing Address - Fax:
Practice Address - Street 1:275 MILLER AVE STE 101
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-2851
Practice Address - Country:US
Practice Address - Phone:415-383-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PSY14513103TC2200X, 103TF0000X
CAPSY14513103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily