=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295020485
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JORDAN CHAUSSE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2011
-----------------------------------------------------
Last Update Date | 06/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 MAHAN ST
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03766-1315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-443-9639
-----------------------------------------------------
Fax | 603-443-9659
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 334
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03766-0334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-443-9639
-----------------------------------------------------
Fax | 603-443-9659
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE OWNER
-----------------------------------------------------
Name | MS. THERESA ROSE CHAUSSE
-----------------------------------------------------
Credential | AAC
-----------------------------------------------------
Telephone | 603-443-9639
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 647013
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------