Provider Demographics
NPI:1588452197
Name:TAN, JACOB S
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:S
Last Name:TAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:S
Other - Last Name:TAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:733 W LINDEN ST APT A6610
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-3956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9600 CENTER AVE STE 160
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5838
Practice Address - Country:US
Practice Address - Phone:858-264-5858
Practice Address - Fax:858-649-6012
Is Sole Proprietor?:No
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25-431182106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician