Provider Demographics
NPI:1528701497
Name:CHAHALIS, JESSARYN (CPO)
Entity type:Individual
Prefix:
First Name:JESSARYN
Middle Name:
Last Name:CHAHALIS
Suffix:
Gender:F
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 N BRISTOL ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-2318
Mailing Address - Country:US
Mailing Address - Phone:253-281-3797
Mailing Address - Fax:
Practice Address - Street 1:402 15TH AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3709
Practice Address - Country:US
Practice Address - Phone:253-697-5278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPS61107102224P00000X
WAOI61107101222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist