MEDICARE: JERMAINE L BROWN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	14502074	TX

General Provider Information

NPI Number	:	1477076560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERMAINE L BROWN

Provider Business Mailing Address
First Line	:	4631 CALLERY CREEK DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77053-3352
Country	:	US
Telephone Number	:	832-432-1656
Fax Number	:

Provider Business Practice Location Address
First Line	:	4631 CALLERY CREEK DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77053
Country	:	US
Telephone Number	:	832-432-1656
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2017
Last Update Date	:	08/17/2017

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