Healthcare Provider Details

I. General information

NPI: 1518377043
Provider Name (Legal Business Name): JIMMY BROWN CG60273706
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2014
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 TACOMA AVE S 305
TACOMA WA
98402-1903
US

IV. Provider business mailing address

10104 107TH STREET CT SW
LAKEWOOD WA
98498-2943
US

V. Phone/Fax

Practice location:
  • Phone: 253-396-5800
  • Fax: 253-383-5548
Mailing address:
  • Phone: 360-628-1304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60273706
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: