Provider Demographics
NPI:1598079394
Name:BROWN, JESSICA ANN (LAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:BROWN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 23RD ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2951
Mailing Address - Country:US
Mailing Address - Phone:701-293-5429
Mailing Address - Fax:107-293-0736
Practice Address - Street 1:1202 23RD ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2951
Practice Address - Country:US
Practice Address - Phone:701-293-5429
Practice Address - Fax:107-293-0736
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility