Provider Demographics
NPI:1811926934
Name:CHIBUK, JASON (MS, CGC)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:CHIBUK
Suffix:
Gender:M
Credentials:MS, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4027 PROMONTORY ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5335
Mailing Address - Country:US
Mailing Address - Phone:858-431-6984
Mailing Address - Fax:
Practice Address - Street 1:4027 PROMONTORY ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-5335
Practice Address - Country:US
Practice Address - Phone:858-431-6984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2005052170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12864Medicare UPIN