Basic Information
| Provider Information | |||||||||
| NPI: | 1134784341 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | JENNELL | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5565 AIRPORT HWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436157391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197205800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7140 PORT SYLVANIA DR | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436171176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194754449 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2019 | ||||||||
| LastUpdateDate: | 05/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | C.2002657 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.