Provider Demographics
NPI:1962438937
Name:BROWN, JENNIFER (DO)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8003
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8003
Mailing Address - Country:US
Mailing Address - Phone:920-996-3298
Mailing Address - Fax:920-738-5787
Practice Address - Street 1:4480 W SPENCER ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-9106
Practice Address - Country:US
Practice Address - Phone:920-738-4800
Practice Address - Fax:920-738-5749
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40541207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA005245003OtherMEDICARE PTAN
WI43526800Medicaid
WA005245003OtherMEDICARE PTAN