MEDICARE: MR. JEFFREY BROWN MA LP

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	103T00000X	Psychologist	LP 2069	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730163478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY BROWN MA LP

Provider Business Mailing Address
First Line	:	1405 LILAC DRIVE N
Second Line	:	STE 130
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-4536
Country	:	US
Telephone Number	:	763-566-0922
Fax Number	:	763-503-9194

Provider Business Practice Location Address
First Line	:	1405 LILAC DR N
Second Line	:	STE 130
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-4536
Country	:	US
Telephone Number	:	763-566-0922
Fax Number	:	763-503-9491

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

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	11/12/2010

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