Provider Demographics
NPI:1831616994
Name:BROWN, JACOB (MA)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 SAUSALITO BLVD
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-2327
Mailing Address - Country:US
Mailing Address - Phone:415-845-1940
Mailing Address - Fax:
Practice Address - Street 1:378 SAUSALITO BLVD
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965-2327
Practice Address - Country:US
Practice Address - Phone:415-845-1940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-29
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA141837106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA0901989OtherCALIFORNIA DRIVERS LICENSE