Basic Information
| Provider Information | |||||||||
| NPI: | 1740448026 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | EVERETT | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | RAF LAKENHEATH 48 MDG/SGHC | ||||||||
| Address2: | UNIT 5115 | ||||||||
| City: | APO | ||||||||
| State: | AE | ||||||||
| PostalCode: | 094615115 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 559 VINCENT ST | ||||||||
| Address2: | ATTN: 21 MDOS/SGOW-MENTAL HEALTH CLINIC | ||||||||
| City: | PETERSON AFB | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809141540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195567804 | ||||||||
| FaxNumber: | 7195567399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2008 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1931 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | C006484 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.