Basic Information
Provider Information | |||||||||
NPI: | 1184792780 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHIGER | ||||||||
FirstName: | JACKIE | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSCCC-A | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3163 STATE ROUTE 42 | ||||||||
Address2: |   | ||||||||
City: | MONTICELLO | ||||||||
State: | NY | ||||||||
PostalCode: | 127014858 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8457947966 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2 FLETCHER ST | ||||||||
Address2: |   | ||||||||
City: | GOSHEN | ||||||||
State: | NY | ||||||||
PostalCode: | 109241402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8452948806 | ||||||||
FaxNumber: | 8452948650 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/01/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 001373 | NY | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
ID Information
ID | Type | State | Issuer | Description | 10106806 | 01 | NY | CDPHP | OTHER | 87766 | 01 | NY | GHI | OTHER | 9Y3021 | 01 | NY | EMPIREBLUECROSSBLUESHIELD | OTHER |