Provider Demographics
NPI:1609471960
Name:BROWN, JA'LISE LYNN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JA'LISE
Middle Name:LYNN
Last Name:BROWN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JA'LISE
Other - Middle Name:LYNN
Other - Last Name:HANEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3415 PEMBERTON SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5886
Mailing Address - Country:US
Mailing Address - Phone:601-641-9953
Mailing Address - Fax:601-767-2318
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-641-9953
Practice Address - Fax:601-767-2318
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM9293104100000X
MSC106061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker