Provider Demographics
NPI:1154074045
Name:CHICAS, JACOB J
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:J
Last Name:CHICAS
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 1:21600 OXNARD ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-4976
Mailing Address - Country:US
Mailing Address - Phone:818-345-2345
Mailing Address - Fax:
Practice Address - Street 1:7920 WYOMING BLVD NE STE A1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-6020
Practice Address - Country:US
Practice Address - Phone:505-420-4126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM513880782106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician