Provider Demographics
NPI:1952153306
Name:CHACON, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:CHACON
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 1:1512 JELLICK AVE APT B
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-2026
Mailing Address - Country:US
Mailing Address - Phone:626-527-5740
Mailing Address - Fax:
Practice Address - Street 1:1500 S HAVEN AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-2969
Practice Address - Country:US
Practice Address - Phone:909-749-5204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician