Provider Demographics
NPI:1376201772
Name:JACK, CHARLES (PHD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:JACK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5178 PARKER RD
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075
Mailing Address - Country:US
Mailing Address - Phone:716-598-8827
Mailing Address - Fax:
Practice Address - Street 1:5178 PARKER RD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075
Practice Address - Country:US
Practice Address - Phone:716-598-8827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
NJ35SI00726500103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist