Provider Demographics
NPI:1083804462
Name:COBB, CHANTAL JACKQUELINE
Entity Type:Individual
Prefix:MRS
First Name:CHANTAL
Middle Name:JACKQUELINE
Last Name:COBB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5816 DICKSON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-4600
Mailing Address - Country:US
Mailing Address - Phone:904-993-7048
Mailing Address - Fax:904-744-0293
Practice Address - Street 1:5816 DICKSON RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-4600
Practice Address - Country:US
Practice Address - Phone:904-993-7048
Practice Address - Fax:904-744-0293
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 18829171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor