Provider Demographics
NPI:1457378903
Name:CHARLES T JAX & ASSOCIATES PC
Entity Type:Organization
Organization Name:CHARLES T JAX & ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:T
Authorized Official - Last Name:JAX
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW BCD ABDA SAP
Authorized Official - Phone:586-751-0999
Mailing Address - Street 1:12200 E 13 MILE RD
Mailing Address - Street 2:STE 150
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3096
Mailing Address - Country:US
Mailing Address - Phone:586-751-0999
Mailing Address - Fax:586-751-1703
Practice Address - Street 1:12200 E 13 MILE RD
Practice Address - Street 2:STE 150
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3096
Practice Address - Country:US
Practice Address - Phone:586-751-0999
Practice Address - Fax:586-751-1703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0891149Medicare ID - Type Unspecified