Healthcare Provider Details

I. General information

NPI: 1013543750
Provider Name (Legal Business Name): JACQUETTE SHINEESE BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2020
Last Update Date: 08/09/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 S DOBSON RD STE 211
MESA AZ
85202-5663
US

IV. Provider business mailing address

20987 N JOHN WAYNE PKWY # B104-113
MARICOPA AZ
85139-2926
US

V. Phone/Fax

Practice location:
  • Phone: 520-251-1575
  • Fax: 520-635-4758
Mailing address:
  • Phone: 520-251-1575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-18852
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401020212
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: