Provider Demographics
NPI:1134846454
Name:BROWN, JACOB (LMHCA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6110 DEER TRACE CT
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47122-0119
Mailing Address - Country:US
Mailing Address - Phone:502-345-4772
Mailing Address - Fax:
Practice Address - Street 1:2420 E 10TH ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-6000
Practice Address - Country:US
Practice Address - Phone:812-282-8248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99114757A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health