Provider Demographics
NPI:1114276342
Name:TABAK, JERRY (LCSW)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:TABAK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 CHURCH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2894
Mailing Address - Country:US
Mailing Address - Phone:636-294-0015
Mailing Address - Fax:
Practice Address - Street 1:109 CHURCH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2894
Practice Address - Country:US
Practice Address - Phone:636-294-0015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-04
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0022171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical