Provider Demographics
NPI:1063297323
Name:BROWN, JACK D
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 W GANSON ST STE 105
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1262
Mailing Address - Country:US
Mailing Address - Phone:517-990-0279
Mailing Address - Fax:
Practice Address - Street 1:505 CHURCHGROVE RD
Practice Address - Street 2:
Practice Address - City:FRANKENMUTH
Practice Address - State:MI
Practice Address - Zip Code:48734-9700
Practice Address - Country:US
Practice Address - Phone:989-233-7196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator