Provider Demographics
NPI:1821786864
Name:CHISM, JAIDEN M
Entity Type:Individual
Prefix:
First Name:JAIDEN
Middle Name:M
Last Name:CHISM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 WILLIAM D FITCH PKWY
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-6141
Mailing Address - Country:US
Mailing Address - Phone:972-850-0899
Mailing Address - Fax:
Practice Address - Street 1:555 WILLIAM D FITCH PKWY
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6141
Practice Address - Country:US
Practice Address - Phone:972-850-0899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX820777106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician