Provider Demographics
NPI:1679032221
Name:TABB, JENNIFER (CARE REP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TABB
Suffix:
Gender:F
Credentials:CARE REP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 SUWANNEE TRAIL ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7956
Mailing Address - Country:US
Mailing Address - Phone:270-901-5000
Mailing Address - Fax:270-842-5268
Practice Address - Street 1:380 SUWANNEE TRAIL ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7956
Practice Address - Country:US
Practice Address - Phone:270-901-5000
Practice Address - Fax:270-842-5268
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid