Provider Demographics
NPI:1790102044
Name:BROWN, JESSICA MICHELLE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MICHELLE
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 POINTE CIR STE 3102
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-6307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:68 POINTE CIR STE 3102
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6307
Practice Address - Country:US
Practice Address - Phone:803-403-0294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC211333163WC1500X
SC25364363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid