Provider Demographics
NPI:1871017814
Name:BROWN, JACQUELINE DIANA
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DIANA
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17860 WEXFORD TER APT 2H
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-3019
Mailing Address - Country:US
Mailing Address - Phone:917-804-2133
Mailing Address - Fax:
Practice Address - Street 1:7210 112TH ST OFC B
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-5467
Practice Address - Country:US
Practice Address - Phone:917-804-2133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005592101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health