Provider Demographics
NPI:1861580821
Name:DUTES, JEAN-CLAUDE (PHD)
Entity type:Individual
Prefix:
First Name:JEAN-CLAUDE
Middle Name:
Last Name:DUTES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 GLADES RD BLDG AZ-79
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-6424
Mailing Address - Country:US
Mailing Address - Phone:561-557-1190
Mailing Address - Fax:
Practice Address - Street 1:777 GLADES RD BLDG AZ-79
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6424
Practice Address - Country:US
Practice Address - Phone:561-557-1190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006498103T00000X
FLLPY19103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C36082093Medicare ID - Type Unspecified