Provider Demographics
NPI:1467772806
Name:TANNER, JACOB C
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:C
Last Name:TANNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 N MERIDIAN AVE SPC 71
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-1317
Mailing Address - Country:US
Mailing Address - Phone:909-913-3403
Mailing Address - Fax:
Practice Address - Street 1:13800 HEACOCK ST STE C236
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3364
Practice Address - Country:US
Practice Address - Phone:951-656-2614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health