Provider Demographics
NPI:1518377043
Name:BROWN, JIMMY (CG60273706)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:CG60273706
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10104 107TH STREET CT SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98498-2943
Mailing Address - Country:US
Mailing Address - Phone:360-628-1304
Mailing Address - Fax:
Practice Address - Street 1:1305 TACOMA AVE S
Practice Address - Street 2:305
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1903
Practice Address - Country:US
Practice Address - Phone:253-396-5800
Practice Address - Fax:253-383-5548
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60273706101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health