=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932406998
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES RICHARD JONASSAINT PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2011
-----------------------------------------------------
Last Update Date | 02/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2024 E MONUMENT ST SUITE 1-500D
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21287-0007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-502-8696
-----------------------------------------------------
Fax | 410-502-6446
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1412 NORTHGATE RD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21218-1549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-219-7481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------