Provider Demographics
NPI:1245896612
Name:CHABOT, JACE MICHAEL
Entity type:Individual
Prefix:
First Name:JACE
Middle Name:MICHAEL
Last Name:CHABOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-7516
Mailing Address - Country:US
Mailing Address - Phone:707-776-7585
Mailing Address - Fax:
Practice Address - Street 1:2 PADRE PKWY STE 101
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2114
Practice Address - Country:US
Practice Address - Phone:707-553-1784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-11
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA09851726OtherKAISER PERMANENTE