Healthcare Provider Details

I. General information

NPI: 1447170618
Provider Name (Legal Business Name): JACOB MORRIS TABACK LCSWA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5007 PROVIDENCE RD STE 105
CHARLOTTE NC
28226-5907
US

IV. Provider business mailing address

4015 CRAFT ST
CHARLOTTE NC
28217-1651
US

V. Phone/Fax

Practice location:
  • Phone: 704-364-6594
  • Fax: 704-364-6596
Mailing address:
  • Phone: 704-589-7598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP024054
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: