Healthcare Provider Details

I. General information

NPI: 1154051209
Provider Name (Legal Business Name): CHANELLE KRISTEN JASSO MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

90 N SUMMIT ST
AKRON OH
44308-1951
US

IV. Provider business mailing address

13248 SPRUCE RUN DR APT 205
NORTH ROYALTON OH
44133-7482
US

V. Phone/Fax

Practice location:
  • Phone: 234-571-9110
  • Fax: 234-571-9107
Mailing address:
  • Phone: 480-202-8742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: