Provider Demographics
NPI:1386822344
Name:CHACKO, JACOB (PT)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:CHACKO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 W CANFORD PARK
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-6667
Mailing Address - Country:US
Mailing Address - Phone:248-935-3364
Mailing Address - Fax:734-983-0575
Practice Address - Street 1:261 W CANFORD PARK
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-6667
Practice Address - Country:US
Practice Address - Phone:248-935-3364
Practice Address - Fax:734-983-0575
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009281225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN82100001Medicare PIN