Provider Demographics
NPI:1902350390
Name:JACOB, TANNA MARIE (MA MFTA)
Entity Type:Individual
Prefix:
First Name:TANNA
Middle Name:MARIE
Last Name:JACOB
Suffix:
Gender:F
Credentials:MA MFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 919
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92836-0919
Mailing Address - Country:US
Mailing Address - Phone:714-680-9000
Mailing Address - Fax:714-680-8233
Practice Address - Street 1:801 E CHAPMAN AVE
Practice Address - Street 2:#203
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3839
Practice Address - Country:US
Practice Address - Phone:714-680-9000
Practice Address - Fax:714-680-8233
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X
390200000X
CA112743106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program