Healthcare Provider Details

I. General information

NPI: 1134846454
Provider Name (Legal Business Name): JACOB BROWN LMHCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 E 10TH ST
JEFFERSONVILLE IN
47130-6000
US

IV. Provider business mailing address

6110 DEER TRACE CT
GEORGETOWN IN
47122-0119
US

V. Phone/Fax

Practice location:
  • Phone: 812-282-8248
  • Fax:
Mailing address:
  • Phone: 502-345-4772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number99114757A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: