Provider Demographics
NPI:1457719759
Name:BROWN, JACKIE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
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 1:305 FORK RD
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN INN
Mailing Address - State:SC
Mailing Address - Zip Code:29644-9477
Mailing Address - Country:US
Mailing Address - Phone:678-463-2467
Mailing Address - Fax:
Practice Address - Street 1:305 FORK RD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:SC
Practice Address - Zip Code:29644-9477
Practice Address - Country:US
Practice Address - Phone:678-463-2467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker