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General NPI Number Information
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NPI Number | 1598778458
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Entity Type | Individual
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Provider Name | JEBIN MATHEW CHACKO MD
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Gender | Male
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Dates
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Enumeration Date | 08/14/2006
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Last Update Date | 09/14/2012
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Provider Practice Location Address
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Address Line | 1701 3RD ST SE
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City | PUYALLUP
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State | WA
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Zip | 98372-4511
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Country | US
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Telephone | 253-697-4747
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Fax |
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Provider Business Mailing Address
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Address Line | 1701 3RD ST SE
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City | PUYALLUP
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State | WA
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Zip | 98372-4511
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Country | US
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Telephone | 253-697-4747
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 242143
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | MD60294851
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License Number State | WA
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