Healthcare Provider Details

I. General information

NPI: 1164194817
Provider Name (Legal Business Name): JESSICA M BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 STOLP AVE
SYRACUSE NY
13207-1333
US

IV. Provider business mailing address

428 STOLP AVE
SYRACUSE NY
13207-1333
US

V. Phone/Fax

Practice location:
  • Phone: 315-231-1603
  • Fax:
Mailing address:
  • Phone: 315-231-1603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: