Provider Demographics
NPI:1073274122
Name:CHARLES, JEAN WIDZARD
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:WIDZARD
Last Name:CHARLES
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 1:3400 KNOLLS RD
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-2814
Mailing Address - Country:US
Mailing Address - Phone:954-505-3265
Mailing Address - Fax:
Practice Address - Street 1:3400 KNOLLS RD
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-2814
Practice Address - Country:US
Practice Address - Phone:954-505-3265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-31
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician