Provider Demographics
NPI:1497807796
Name:TABBERT, JERALD F (MSSW)
Entity type:Individual
Prefix:
First Name:JERALD
Middle Name:F
Last Name:TABBERT
Suffix:
Gender:M
Credentials:MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:123 16TH AVE S
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-3109
Practice Address - Country:US
Practice Address - Phone:608-775-8646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7590-1231041C0700X
WI16091-130101YA0400X
WI75901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40906100Medicaid
WI40906100Medicaid