Basic Information
| Provider Information | |||||||||
| NPI: | 1366868028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING BROWN | ||||||||
| FirstName: | JILLIAN | ||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | KING | ||||||||
| OtherFirstName: | JILLIAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2632 | ||||||||
| Address2: | |||||||||
| City: | LAKE ISABELLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932402632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603793412 | ||||||||
| FaxNumber: | 7603795332 | ||||||||
| Practice Location | |||||||||
| Address1: | 2731 NUGGET AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE ISABELLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603793412 | ||||||||
| FaxNumber: | 7603795332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2014 | ||||||||
| LastUpdateDate: | 05/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.