Provider Demographics
NPI:1659403996
Name:BROWN, JACQUELINE MARIE (RN,MSN, FNP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MARIE
Last Name:BROWN
Suffix:
Gender:F
Credentials:RN,MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 BARNES AVE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-2138
Mailing Address - Country:US
Mailing Address - Phone:716-384-5446
Mailing Address - Fax:719-384-5672
Practice Address - Street 1:100 KENDALL DR
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052-3901
Practice Address - Country:US
Practice Address - Phone:716-366-9154
Practice Address - Fax:719-336-7453
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO72910163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07729106Medicaid