Provider Demographics
NPI:1528577483
Name:BROWN-JACOBS, MARY (EDD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:BROWN-JACOBS
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 CANVAS CT
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-4338
Mailing Address - Country:US
Mailing Address - Phone:1817-996-3138
Mailing Address - Fax:
Practice Address - Street 1:501 CANVAS CT
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-4338
Practice Address - Country:US
Practice Address - Phone:817-996-3138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-22
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16071202305R00000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No305R00000XManaged Care OrganizationsPreferred Provider Organization