Provider Demographics
NPI:1508338567
Name:CHARLES, JERRY JR (NP)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:CHARLES
Suffix:JR
Gender:M
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:1340 BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-4302
Mailing Address - Country:US
Mailing Address - Phone:617-267-0900
Mailing Address - Fax:617-867-8646
Practice Address - Street 1:1340 BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-4302
Practice Address - Country:US
Practice Address - Phone:617-267-0900
Practice Address - Fax:617-867-8646
Is Sole Proprietor?:No
Enumeration Date:2018-12-31
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MARN2348883363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily