Healthcare Provider Details

I. General information

NPI: 1528701497
Provider Name (Legal Business Name): JESSARYN CHAHALIS CPO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 15TH AVE SE STE 100
PUYALLUP WA
98372-3709
US

IV. Provider business mailing address

2605 N BRISTOL ST
TACOMA WA
98407-2318
US

V. Phone/Fax

Practice location:
  • Phone: 253-697-5278
  • Fax:
Mailing address:
  • Phone: 253-281-3797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberOI61107101
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPS61107102
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: