Charles Jack, PH.D.

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

35SI00726500 Issued in NJ

Practice address

5178 Parker Rd
Hamburg, NY 14075

Phone

(716) 598-8827

NPI assigned

Dec 2, 2021

Sex

Male

Sole proprietor

Yes

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Bhcofwny

  • Clinical Psychologist
  • Hamburg, NY
  • NPI 1689393191

  Clinical

  NPD Authorized official
• Senior Care Therapy LLC

  • Clinical Psychologist
  • Passaic, NJ
  • NPI 1285898098

  Clinical

  NPD

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: No
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Philosophy

Practice roles

Locations

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Nov 24, 2023.

{
    "created_epoch": "1638403200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1700784000000",
    "number": "1376201772",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5178 PARKER RD",
            "city": "HAMBURG",
            "state": "NY",
            "postal_code": "14075",
            "telephone_number": "716-598-8827"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5178 PARKER RD",
            "city": "HAMBURG",
            "state": "NY",
            "postal_code": "14075",
            "telephone_number": "716-598-8827"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACK",
        "first_name": "CHARLES",
        "name_prefix": "Dr.",
        "credential": "PH.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2021-12-02",
        "last_updated": "2023-11-24",
        "certification_date": "2021-12-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "NJ",
            "license": "35SI00726500",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "mail@BHCofWNY.com",
            "affiliation": "N",
            "endpointDescription": "protected email",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "5178 Parker Rd",
            "city": "Hamburg",
            "state": "NY",
            "country_code": "US",
            "postal_code": "140751633",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Frances Renee Ide, MS., ED
• Leia K Ince-Mercer, MD
• Jeremy Ingersoll
• Sarah Insley
• J. Rutowski of Wanakah Inc.
• Sidney F Jack, DDS
• Jennifer Leigh Jacobs, RN, BSN
• Jamestown Rehab Service PT, OT, SLP, PLLC.
• Heather Janik, MD
• Taylor N Janosz, PT, DPT

• All providers in Hamburg, NY
• Clinical Psychologist in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 24, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.