Provider Demographics
NPI:1780672774
Name:BROWN, JANE WILSON (PHD)
Entity Type:Individual
Prefix:MRS
First Name:JANE
Middle Name:WILSON
Last Name:BROWN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MISS
Other - First Name:JANE
Other - Middle Name:GORDON
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:281 INDEPENDENCE BLVD
Mailing Address - Street 2:STE 326
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-2986
Mailing Address - Country:US
Mailing Address - Phone:757-490-0377
Mailing Address - Fax:757-497-1327
Practice Address - Street 1:281 INDEPENDENCE BLVD
Practice Address - Street 2:STE 326
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-2986
Practice Address - Country:US
Practice Address - Phone:757-490-0377
Practice Address - Fax:757-497-1327
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001804103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010239354Medicaid
R89344Medicare UPIN
VA010239354Medicaid