Healthcare Provider Details

I. General information

NPI: 1356748081
Provider Name (Legal Business Name): JESSAMYN BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 W SANETTA ST
NAMPA ID
83651-5047
US

IV. Provider business mailing address

1031 W SANETTA ST
NAMPA ID
83651-5047
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-7443
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLMSW-34280
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: