Provider Demographics
NPI:1396972444
Name:BROWN, JACLYN RENE (MD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:RENE
Last Name:BROWN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 E. WARNER RD.
Mailing Address - Street 2:SUITE 107
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3073
Mailing Address - Country:US
Mailing Address - Phone:480-539-8680
Mailing Address - Fax:480-539-1763
Practice Address - Street 1:652 E. WARNER RD.
Practice Address - Street 2:SUITE 107
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3073
Practice Address - Country:US
Practice Address - Phone:480-539-8680
Practice Address - Fax:480-539-1763
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ46360207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ67803OtherPTAN