Basic Information
| Provider Information | |||||||||
| NPI: | 1124315122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | |||||||||
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| Credential: | MHPP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 829 HALBERT ST | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721042607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013324400 | ||||||||
| FaxNumber: | 5013324403 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HOPE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718017243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708879000 | ||||||||
| FaxNumber: | 8708879001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2011 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.