Provider Demographics
NPI:1376016246
Name:TABAK, JILLIAN NICOLE (MSW, LCSW, LCAS)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:NICOLE
Last Name:TABAK
Suffix:
Gender:F
Credentials:MSW, LCSW, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 PHYSICIANS DR STE 104
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7348
Mailing Address - Country:US
Mailing Address - Phone:610-304-6743
Mailing Address - Fax:
Practice Address - Street 1:1606 PHYSICIANS DR STE 104
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7348
Practice Address - Country:US
Practice Address - Phone:610-304-6743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0135241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical