Healthcare Provider Details

I. General information

NPI: 1225232721
Provider Name (Legal Business Name): JEREMY JAMES CHAILLET MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 TOWN CENTER PKWY
RESTON VA
20190-3219
US

IV. Provider business mailing address

36 WOODLAND PARK
HARTFORD CT
06105-1219
US

V. Phone/Fax

Practice location:
  • Phone: 703-689-9000
  • Fax:
Mailing address:
  • Phone: 608-217-3724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number272928
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number146355
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101241899
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: