Healthcare Provider Details

I. General information

NPI: 1083117642
Provider Name (Legal Business Name): JULIE JORDAN BROWN CCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 S 103RD ST STE 200
MILWAUKEE WI
53227-4163
US

IV. Provider business mailing address

3400 S 103RD ST STE 200
MILWAUKEE WI
53227-4163
US

V. Phone/Fax

Practice location:
  • Phone: 414-543-1002
  • Fax: 414-543-0137
Mailing address:
  • Phone: 414-543-1002
  • Fax: 414-543-0137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code229N00000X
TaxonomyAnaplastologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: