Provider Demographics
NPI:1962604173
Name:CHARRON, JESSICA (PSYD, LP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CHARRON
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 BISCAYNE WAY
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-8410
Mailing Address - Country:US
Mailing Address - Phone:517-410-8512
Mailing Address - Fax:517-675-8091
Practice Address - Street 1:119 PERE MARQUETTE DR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1270
Practice Address - Country:US
Practice Address - Phone:734-531-7763
Practice Address - Fax:517-675-8091
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013199103TC0700X
MI6301014379103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical