Provider Demographics
NPI:1104466168
Name:TABACO, JENE FER
Entity type:Individual
Prefix:
First Name:JENE FER
Middle Name:
Last Name:TABACO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 WOODLAND COURT 3B
Mailing Address - Street 2:
Mailing Address - City:CARPENTERSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60110
Mailing Address - Country:US
Mailing Address - Phone:224-258-5116
Mailing Address - Fax:
Practice Address - Street 1:104 WOODLAND COURT 3B
Practice Address - Street 2:
Practice Address - City:CARPENTERSVILLE
Practice Address - State:IL
Practice Address - Zip Code:60110
Practice Address - Country:US
Practice Address - Phone:224-258-5116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.022890225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist