Provider Demographics
NPI:1598778458
Name:CHACKO, JEBIN MATHEW (MD)
Entity Type:Individual
Prefix:
First Name:JEBIN
Middle Name:MATHEW
Last Name:CHACKO
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 1:1701 3RD ST SE
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-4511
Mailing Address - Country:US
Mailing Address - Phone:253-697-4747
Mailing Address - Fax:
Practice Address - Street 1:1701 3RD ST SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-4511
Practice Address - Country:US
Practice Address - Phone:253-697-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2421432084N0400X
WAMD602948512084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02888195Medicaid
NY02888195Medicaid