MEDICARE: DR. JESSICA M BROWN PSYD LP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	LP4014	MN

General Provider Information

NPI Number	:	1679500516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JESSICA M BROWN PSYD LP

Provider Business Mailing Address
First Line	:	2809 WAYZATA BLVD S
Second Line	:
City	:	MPLS
State	:	MN
Zip	:	55405
Country	:	US
Telephone Number	:	612-377-9190
Fax Number	:	612-374-4498

Provider Business Practice Location Address
First Line	:	2809 WAYZATA BLVD S
Second Line	:
City	:	MPLS
State	:	MN
Zip	:	55405
Country	:	US
Telephone Number	:	612-377-9190
Fax Number	:	612-374-4498

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2006
Last Update Date	:	09/29/2010

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