Basic Information
| Provider Information | |||||||||
| NPI: | 1528626504 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | PAIGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4115 MCKINLEY ST NE | ||||||||
| Address2: | |||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985166289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105165899 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8282 28TH CT NE STE A | ||||||||
| Address2: | |||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985167162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609156868 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2019 | ||||||||
| LastUpdateDate: | 03/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.