Provider Demographics
NPI:1043753486
Name:CHASTAIN, JAKE RYAN
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:RYAN
Last Name:CHASTAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 RAINBOW DR
Mailing Address - Street 2:
Mailing Address - City:SEDRO WOOLLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98284-9587
Mailing Address - Country:US
Mailing Address - Phone:425-327-3396
Mailing Address - Fax:
Practice Address - Street 1:374 RAINBOW DR
Practice Address - Street 2:
Practice Address - City:SEDRO WOOLLEY
Practice Address - State:WA
Practice Address - Zip Code:98284-9587
Practice Address - Country:US
Practice Address - Phone:425-327-3396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAES. 60623189146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic