Healthcare Provider Details

I. General information

NPI: 1972202513
Provider Name (Legal Business Name): JESSICA BROWN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2023
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5014 MONUMENT AVE
RICHMOND VA
23230-3620
US

IV. Provider business mailing address

12040 KENTON RIDGE RD
ASHLAND VA
23005-7556
US

V. Phone/Fax

Practice location:
  • Phone: 804-497-4676
  • Fax:
Mailing address:
  • Phone: 804-337-0991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904014907
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: