Provider Demographics
NPI:1144007626
Name:CHACKO, JACOB PULPRAYIL
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:PULPRAYIL
Last Name:CHACKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 COLONY LAKE ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:TX
Mailing Address - Zip Code:77477-4596
Mailing Address - Country:US
Mailing Address - Phone:832-228-5338
Mailing Address - Fax:
Practice Address - Street 1:506 COLONY LAKE ESTATES DR
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-4596
Practice Address - Country:US
Practice Address - Phone:832-228-5338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT137796225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty