Provider Demographics
NPI:1619180718
Name:BROWN, JERRILEE (MS-CFY-SLP)
Entity Type:Individual
Prefix:
First Name:JERRILEE
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:MS-CFY-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9021
Mailing Address - Country:US
Mailing Address - Phone:505-599-8535
Mailing Address - Fax:505-599-8536
Practice Address - Street 1:1309 E 20TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-9021
Practice Address - Country:US
Practice Address - Phone:505-599-8535
Practice Address - Fax:505-599-8536
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4052235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4052OtherR&L STATE BOARD