MEDICARE: MR. JASON CHIBUK MS, CGC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	170300000X	Genetic Counselor (M.S.)	2005052	CA

General Provider Information

NPI Number	:	1811926934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JASON CHIBUK MS, CGC

Provider Business Mailing Address
First Line	:	4027 PROMONTORY ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-5335
Country	:	US
Telephone Number	:	858-431-6984
Fax Number	:

Provider Business Practice Location Address
First Line	:	4027 PROMONTORY ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-5335
Country	:	US
Telephone Number	:	858-431-6984
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	07/09/2007

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