Provider Demographics
NPI:1760727663
Name:CHACKO, JESSY (PA)
Entity Type:Individual
Prefix:
First Name:JESSY
Middle Name:
Last Name:CHACKO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 COMMUNITY DR
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3816
Practice Address - Country:US
Practice Address - Phone:516-562-4676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015945363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical