Healthcare Provider Details

I. General information

NPI: 1467591289
Provider Name (Legal Business Name): JERRY W BROWN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 RIVERSIDE PLAZA LN NW SUITE 100
ALBUQUERQUE NM
87120-2617
US

IV. Provider business mailing address

PO BOX 94508
ALBUQUERQUE NM
87199-4508
US

V. Phone/Fax

Practice location:
  • Phone: 505-400-7282
  • Fax:
Mailing address:
  • Phone: 505-400-7282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2389
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2389
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: