Provider Demographics
NPI:1932898947
Name:BROWN, JACKIE SI'DELAVET
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:SI'DELAVET
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 1:2512 FOX LN
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-2090
Mailing Address - Country:US
Mailing Address - Phone:772-563-3877
Mailing Address - Fax:
Practice Address - Street 1:2512 FOX LN
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2090
Practice Address - Country:US
Practice Address - Phone:772-563-3877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider