Provider Demographics
NPI:1578138384
Name:BROWN, JONATHAN KEITH (LMSW)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:KEITH
Last Name:BROWN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2001
Mailing Address - Country:US
Mailing Address - Phone:706-594-0504
Mailing Address - Fax:
Practice Address - Street 1:523 DIXIE ST STE 1
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3870
Practice Address - Country:US
Practice Address - Phone:770-812-3266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW004666104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker