Healthcare Provider Details

I. General information

NPI: 1639456825
Provider Name (Legal Business Name): JACQUELINE JOHNETTE BROWN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2011
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18197 VIRGINIA AVE
BOYKINS VA
23827-2767
US

IV. Provider business mailing address

18197 VIRGINIA AVE
BOYKINS VA
23827-2767
US

V. Phone/Fax

Practice location:
  • Phone: 757-654-6226
  • Fax:
Mailing address:
  • Phone: 757-654-6226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401413387
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: