Provider Demographics
NPI:1790273852
Name:CHACKO, JESSICA NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:NICOLE
Last Name:CHACKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:12649 HORSESHOE BEND DR
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-3311
Mailing Address - Country:US
Mailing Address - Phone:775-233-7196
Mailing Address - Fax:813-576-0892
Practice Address - Street 1:12649 HORSESHOE BEND DR
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-3311
Practice Address - Country:US
Practice Address - Phone:775-233-7196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME150652208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics