Provider Demographics
NPI:1093538134
Name:CHAVEZ, JACOB A (PTA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:A
Last Name:CHAVEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-2471
Mailing Address - Country:US
Mailing Address - Phone:719-553-6949
Mailing Address - Fax:
Practice Address - Street 1:901 N SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-1738
Practice Address - Country:US
Practice Address - Phone:719-822-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0015038225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant