Provider Demographics
NPI:1386001832
Name:FABRA, JOHNETTE (CP 00002876)
Entity Type:Individual
Prefix:
First Name:JOHNETTE
Middle Name:
Last Name:FABRA
Suffix:
Gender:F
Credentials:CP 00002876
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 S 28TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-8020
Mailing Address - Country:US
Mailing Address - Phone:253-680-2691
Mailing Address - Fax:
Practice Address - Street 1:1016 S 28TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-8020
Practice Address - Country:US
Practice Address - Phone:253-680-2691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-27
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP 00002876101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)