Provider Demographics
NPI:1821577628
Name:QUATTLEBAUM, JAHN
Entity Type:Individual
Prefix:
First Name:JAHN
Middle Name:
Last Name:QUATTLEBAUM
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 1:6200 WILSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4159
Mailing Address - Country:US
Mailing Address - Phone:903-216-6641
Mailing Address - Fax:
Practice Address - Street 1:6200 WILSHIRE DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4159
Practice Address - Country:US
Practice Address - Phone:903-216-6641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12272101YA0400X
COLPC.0014807101YM0800X
TX71752101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)