Provider Demographics
NPI:1104176049
Name:BROWN, JETUWAN M (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:JETUWAN
Middle Name:M
Last Name:BROWN
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:JETUWAN
Other - Middle Name:Y
Other - Last Name:MCGRUDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:103 HONOURS DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6513
Mailing Address - Country:US
Mailing Address - Phone:601-278-6710
Mailing Address - Fax:
Practice Address - Street 1:115 AULENBROCK DR STE A
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-7061
Practice Address - Country:US
Practice Address - Phone:601-278-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR875060163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse