Provider Demographics
NPI:1134784341
Name:BROWN, JENNELL MARIE
Entity type:Individual
Prefix:
First Name:JENNELL
Middle Name:MARIE
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 1:5565 AIRPORT HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-7391
Mailing Address - Country:US
Mailing Address - Phone:419-720-5800
Mailing Address - Fax:
Practice Address - Street 1:7140 PORT SYLVANIA DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1176
Practice Address - Country:US
Practice Address - Phone:419-475-4449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OHC.2002657101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program