Basic Information
| Provider Information | |||||||||
| NPI: | 1457378903 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHARLES T JAX & ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12200 E 13 MILE RD | ||||||||
| Address2: | STE 150 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867510999 | ||||||||
| FaxNumber: | 5867511703 | ||||||||
| Practice Location | |||||||||
| Address1: | 12200 E 13 MILE RD | ||||||||
| Address2: | STE 150 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867510999 | ||||||||
| FaxNumber: | 5867511703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | JAX | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRES | ||||||||
| AuthorizedOfficialTelephone: | 5867510999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMSW BCD ABDA SAP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.