Provider Demographics
NPI:1669920542
Name:JACQUES, CHARLES EDMUND
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:EDMUND
Last Name:JACQUES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 GOULD ST
Mailing Address - Street 2:
Mailing Address - City:WARE
Mailing Address - State:MA
Mailing Address - Zip Code:01082-1316
Mailing Address - Country:US
Mailing Address - Phone:413-207-1526
Mailing Address - Fax:
Practice Address - Street 1:50 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3909
Practice Address - Country:US
Practice Address - Phone:413-584-6855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11492101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health