Provider Demographics
NPI:1699116269
Name:CHARBONEAU, JAY F (SW)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:F
Last Name:CHARBONEAU
Suffix:
Gender:M
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3604
Mailing Address - Country:US
Mailing Address - Phone:904-647-8576
Mailing Address - Fax:904-253-3098
Practice Address - Street 1:2570 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-3604
Practice Address - Country:US
Practice Address - Phone:904-647-8576
Practice Address - Fax:904-253-3098
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10381101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health