Provider Demographics
NPI:1679331458
Name:WHITE, JAN QUINTON
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:QUINTON
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 1:600 WILLIAM ST APT 246
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-5408
Mailing Address - Country:US
Mailing Address - Phone:510-355-4870
Mailing Address - Fax:
Practice Address - Street 1:600 WILLIAM ST APT 246
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-5408
Practice Address - Country:US
Practice Address - Phone:510-355-4870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA5732814343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)