Basic Information
| Provider Information | |||||||||
| NPI: | 1780162313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHINCHILLA | ||||||||
| FirstName: | JESSECA | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 SW SALMON ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972042908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
| FaxNumber: | 7726759100 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 SW SALMON ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972042908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
| FaxNumber: | 7726759100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2018 | ||||||||
| LastUpdateDate: | 08/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | RBT-18-48855 | TX | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.