Provider Demographics
NPI:1144794710
Name:WHITE, QUENDERRION MARQUEZ
Entity Type:Individual
Prefix:MR
First Name:QUENDERRION
Middle Name:MARQUEZ
Last Name:WHITE
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:PO BOX 1243
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-0026
Mailing Address - Country:US
Mailing Address - Phone:404-695-2195
Mailing Address - Fax:
Practice Address - Street 1:124 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-3599
Practice Address - Country:US
Practice Address - Phone:404-695-2195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
GA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician