Provider Demographics
NPI:1063537512
Name:TACBAS, JEREMY (LMFT, BCBA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:TACBAS
Suffix:
Gender:M
Credentials:LMFT, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N A ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT SHASTA
Mailing Address - State:CA
Mailing Address - Zip Code:96067-2402
Mailing Address - Country:US
Mailing Address - Phone:530-408-8794
Mailing Address - Fax:530-500-2474
Practice Address - Street 1:5727 DUNSMUIR AVE
Practice Address - Street 2:
Practice Address - City:DUNSMUIR
Practice Address - State:CA
Practice Address - Zip Code:96025
Practice Address - Country:US
Practice Address - Phone:530-408-8794
Practice Address - Fax:530-500-2474
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-17-26591103K00000X
CA105850101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst