Basic Information
| Provider Information | |||||||||
| NPI: | 1225578628 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHEVILLE | ||||||||
| FirstName: | JEAN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 ANDERSON DR | ||||||||
| Address2: | |||||||||
| City: | ABERDEEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985201007 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 920 ANDERSON DR | ||||||||
| Address2: | |||||||||
| City: | ABERDEEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985201007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605325122 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2017 | ||||||||
| LastUpdateDate: | 03/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | P160611621 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.