Provider Demographics
NPI:1518111996
Name:QUINN-TAN, JACQUELINE MARY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARY
Last Name:QUINN-TAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 TRINITY PL
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-5006
Mailing Address - Country:US
Mailing Address - Phone:574-272-9000
Mailing Address - Fax:
Practice Address - Street 1:1000 S MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-3426
Practice Address - Country:US
Practice Address - Phone:574-235-5408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-11
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041167A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical