Provider Demographics
NPI:1164096004
Name:QUINN, JEREMY DEAN
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DEAN
Last Name:QUINN
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 1:431 DAWSON AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-3685
Mailing Address - Country:US
Mailing Address - Phone:949-312-8596
Mailing Address - Fax:
Practice Address - Street 1:431 DAWSON AVE APT 8
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90814-3685
Practice Address - Country:US
Practice Address - Phone:949-312-8596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-15
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74755225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist