Provider Demographics
NPI:1235711573
Name:TABER, JACOB EDWARD (DO)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:EDWARD
Last Name:TABER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:740 REENA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-3145
Mailing Address - Country:US
Mailing Address - Phone:920-563-0888
Mailing Address - Fax:920-568-3516
Practice Address - Street 1:740 REENA AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-3145
Practice Address - Country:US
Practice Address - Phone:920-563-0888
Practice Address - Fax:920-568-3516
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI81240-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1235711573Medicaid