MEDICARE: JISHA CHERIAN CHACKO RN, MSN, NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	712285	TX

General Provider Information

NPI Number	:	1073804944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JISHA CHERIAN CHACKO RN, MSN, NP-C

Provider Business Mailing Address
First Line	:	4206 N I 35
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76207-3441
Country	:	US
Telephone Number	:	940-382-6900
Fax Number	:	940-383-2224

Provider Business Practice Location Address
First Line	:	4206 N I 35
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76207-3441
Country	:	US
Telephone Number	:	940-382-6900
Fax Number	:	940-382-1005

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2011
Last Update Date	:	04/15/2022

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