Provider Demographics
NPI:1851796130
Name:TABBADA, JACKIE LOU
Entity Type:Individual
Prefix:
First Name:JACKIE LOU
Middle Name:
Last Name:TABBADA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RONALYN
Other - Middle Name:
Other - Last Name:TAACA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9825 SELVA WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-8210
Mailing Address - Country:US
Mailing Address - Phone:916-601-9336
Mailing Address - Fax:
Practice Address - Street 1:4801 34TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-4849
Practice Address - Country:US
Practice Address - Phone:916-364-8395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA347000518320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness