Healthcare Provider Details

I. General information

NPI: 1205708567
Provider Name (Legal Business Name): JONATHAN WILEY BROWN NP STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 N SWIFT RD
ADDISON IL
60101-6105
US

IV. Provider business mailing address

1221 N SWIFT RD
ADDISON IL
60101-6105
US

V. Phone/Fax

Practice location:
  • Phone: 229-322-6594
  • Fax:
Mailing address:
  • Phone: 229-322-6594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRN275421
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: