Provider Demographics
NPI:1982155768
Name:BROWN, JACK ALAN III
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:ALAN
Last Name:BROWN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ELEMENTAL
Other - Middle Name:HEALING
Other - Last Name:ARTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:200 REDWOOD HWY
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5404
Mailing Address - Country:US
Mailing Address - Phone:541-659-1703
Mailing Address - Fax:
Practice Address - Street 1:200 REDWOOD HWY
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5404
Practice Address - Country:US
Practice Address - Phone:541-659-1703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17531225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist