MEDICARE: MRS. MARIAMA SARA BROWN-JETERS MA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1609574821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARIAMA SARA BROWN-JETERS MA

Provider Business Mailing Address
First Line	:	912 N MAYWOOD DR
Second Line	:
City	:	MAYWOOD
State	:	IL
Zip	:	60153-1862
Country	:	US
Telephone Number	:	312-303-0500
Fax Number	:

Provider Business Practice Location Address
First Line	:	4044 N LINCOLN AVE STE 198
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-3038
Country	:	US
Telephone Number	:	773-217-9087
Fax Number	:

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

Provider Enumeration Date	:	02/16/2023
Last Update Date	:	02/16/2023

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