Provider Demographics
NPI:1245113117
Name:CHACKO, JAKE PHILIP (PT, DPT)
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:PHILIP
Last Name:CHACKO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10452 ALCON BLUE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-4071
Mailing Address - Country:US
Mailing Address - Phone:813-546-8990
Mailing Address - Fax:
Practice Address - Street 1:922 W LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6281
Practice Address - Country:US
Practice Address - Phone:813-651-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-29
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL42101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist