Provider Demographics
NPI:1053847475
Name:CHIDESTER, JASYN SCOTT (ATC)
Entity Type:Individual
Prefix:
First Name:JASYN
Middle Name:SCOTT
Last Name:CHIDESTER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4003 CHEENEY ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95054-2522
Mailing Address - Country:US
Mailing Address - Phone:650-504-0048
Mailing Address - Fax:
Practice Address - Street 1:180 EL CAMINO REAL
Practice Address - Street 2:SUITE M384, OFFICE 229
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304
Practice Address - Country:US
Practice Address - Phone:650-885-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000025880OtherBOC CERTIFIED ATHLETIC TRAINER