Provider Demographics
NPI:1609609940
Name:BROWN, JACOB MACKENZIE
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MACKENZIE
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 1:4901 LAKE ENGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2937
Mailing Address - Country:US
Mailing Address - Phone:806-778-2172
Mailing Address - Fax:
Practice Address - Street 1:700 N ROBINSON DR
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:TX
Practice Address - Zip Code:76706-5050
Practice Address - Country:US
Practice Address - Phone:806-412-4721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX87193101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional