Provider Demographics
NPI:1881637478
Name:BROWN, JERRY MICHEAL SR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:MICHEAL
Last Name:BROWN
Suffix:SR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 WIGWAM DR
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-2269
Mailing Address - Country:US
Mailing Address - Phone:315-387-5040
Mailing Address - Fax:
Practice Address - Street 1:48 WIGWAM DR
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:NY
Practice Address - Zip Code:13142-2269
Practice Address - Country:US
Practice Address - Phone:315-387-5040
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0619251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA0728Medicare ID - Type Unspecified