Provider Demographics
NPI:1437134012
Name:TABER, JENNIFER A (OT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:TABER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:BALDWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:1630 COMMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-5753
Mailing Address - Country:US
Mailing Address - Phone:920-430-4750
Mailing Address - Fax:
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5753
Practice Address - Country:US
Practice Address - Phone:920-430-4750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4173225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4173026OtherLICENSE
WIQ22451Medicare UPIN
WI4173026OtherLICENSE