Healthcare Provider Details

I. General information

NPI: 1396972444
Provider Name (Legal Business Name): JACLYN RENE BROWN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

652 E. WARNER RD. SUITE 107
GILBERT AZ
85296-3073
US

IV. Provider business mailing address

652 E. WARNER RD. SUITE 107
GILBERT AZ
85296-3073
US

V. Phone/Fax

Practice location:
  • Phone: 480-539-8680
  • Fax: 480-539-1763
Mailing address:
  • Phone: 480-539-8680
  • Fax: 480-539-1763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number46360
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number46360
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: