Provider Demographics
NPI:1477270494
Name:CHARLES, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:CHARLES
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 1:613 HAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-3322
Mailing Address - Country:US
Mailing Address - Phone:863-852-5195
Mailing Address - Fax:
Practice Address - Street 1:613 HAMPTON ST
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-3322
Practice Address - Country:US
Practice Address - Phone:863-852-5195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114312700Medicaid