Provider Demographics
NPI:1295526309
Name:CHARLES, JENICA
Entity type:Individual
Prefix:
First Name:JENICA
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 1:20 MILLER ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1831
Mailing Address - Country:US
Mailing Address - Phone:518-565-9577
Mailing Address - Fax:
Practice Address - Street 1:20 MILLER ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1831
Practice Address - Country:US
Practice Address - Phone:518-565-9577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-16
Last Update Date:2025-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health