Healthcare Provider Details

I. General information

NPI: 1679203699
Provider Name (Legal Business Name): JESSICA A CHISM DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9660 E 22ND ST STE 180
TUCSON AZ
85748-7563
US

IV. Provider business mailing address

1238 BLACK OAK DR
SOUTH BEND IN
46617-1702
US

V. Phone/Fax

Practice location:
  • Phone: 520-543-8001
  • Fax:
Mailing address:
  • Phone: 575-210-8448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP053236T
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number99112000A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: