Provider Demographics
NPI:1790088375
Name:BROWN, JERRELL RUSS (LVN)
Entity Type:Individual
Prefix:
First Name:JERRELL
Middle Name:RUSS
Last Name:BROWN
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:75117-0397
Mailing Address - Country:US
Mailing Address - Phone:682-433-1050
Mailing Address - Fax:
Practice Address - Street 1:1101 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4802
Practice Address - Country:US
Practice Address - Phone:817-321-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-21
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX135078164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse