=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366724361
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSE DANIEL CHASMAN PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2011
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1608 PARADISE LAKE DR
-----------------------------------------------------
City | MOUNT PLEASANT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29464-5719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-997-4723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2520
-----------------------------------------------------
City | MOUNT PLEASANT
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29465-2520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-997-4723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | PS01247
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103G00000X
-----------------------------------------------------
Taxonomy Name | Clinical Neuropsychologist
-----------------------------------------------------
License Number | 1449
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------