Provider Demographics
NPI:1619560349
Name:BROWN, JELANI
Entity Type:Individual
Prefix:
First Name:JELANI
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHESTNUT ST APT 118
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4123
Mailing Address - Country:US
Mailing Address - Phone:917-753-0777
Mailing Address - Fax:
Practice Address - Street 1:1833 MOUNT ZION RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-3015
Practice Address - Country:US
Practice Address - Phone:917-753-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN1229891223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY744531758-00Medicaid