Provider Demographics
NPI:1407056799
Name:CHAVES, JESSICA BROOKE (PT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BROOKE
Last Name:CHAVES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 SHOVE ST
Mailing Address - Street 2:
Mailing Address - City:TIVERTON
Mailing Address - State:RI
Mailing Address - Zip Code:02878-1029
Mailing Address - Country:US
Mailing Address - Phone:401-624-4743
Mailing Address - Fax:401-624-9152
Practice Address - Street 1:31 SHOVE ST
Practice Address - Street 2:
Practice Address - City:TIVERTON
Practice Address - State:RI
Practice Address - Zip Code:02878-1029
Practice Address - Country:US
Practice Address - Phone:401-624-4743
Practice Address - Fax:401-624-9152
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
23335-8OtherBLUE CROSS BLUE SHIELD
23335-8OtherBLUE CROSS BLUE SHIELD