Provider Demographics
NPI:1528542321
Name:BROWN, FREDRICK JAMES
Entity type:Individual
Prefix:
First Name:FREDRICK
Middle Name:JAMES
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 1:1034 EDGEWOOD AVE S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-5343
Mailing Address - Country:US
Mailing Address - Phone:904-503-0131
Mailing Address - Fax:
Practice Address - Street 1:1034 EDGEWOOD AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-5343
Practice Address - Country:US
Practice Address - Phone:904-503-0131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-63554106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician