Provider Demographics
NPI:1073879185
Name:CHLEBECK, JESSE DYLAN (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:DYLAN
Last Name:CHLEBECK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 S VANGUARD WAY STE 110
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8541
Mailing Address - Country:US
Mailing Address - Phone:208-595-4440
Mailing Address - Fax:855-592-2514
Practice Address - Street 1:875 S VANGUARD WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8540
Practice Address - Country:US
Practice Address - Phone:208-463-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA148489207X00000X, 207XX0801X
IDM-14245207XX0801X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma