Provider Demographics
NPI:1487159158
Name:BROWN, JEROME
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16165 COLLISION
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MICHIGAN
Mailing Address - Zip Code:48021
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13871 EDMORE DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-1222
Practice Address - Country:US
Practice Address - Phone:313-482-0944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
B650402229974374U00000X
MIB650402229974374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide