Provider Demographics
NPI:1821122052
Name:BROWN, JACQUELYN (PSYD)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1662 PLUM LN STE 102
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4595
Mailing Address - Country:US
Mailing Address - Phone:909-348-3580
Mailing Address - Fax:909-425-6635
Practice Address - Street 1:1662 PLUM LN STE 102
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4595
Practice Address - Country:US
Practice Address - Phone:909-348-3580
Practice Address - Fax:909-425-6635
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAPSY23315103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health