Healthcare Provider Details

I. General information

NPI: 1407780760
Provider Name (Legal Business Name): LUIS FERNANDO JASSO CHAVEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W263N2060 E FIELDHACK DR UNIT 205
PEWAUKEE WI
53072-5405
US

IV. Provider business mailing address

W263N2060 E FIELDHACK DR UNIT 205
PEWAUKEE WI
53072-5405
US

V. Phone/Fax

Practice location:
  • Phone: 414-243-4900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18326-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: