Healthcare Provider Details

I. General information

NPI: 1750998704
Provider Name (Legal Business Name): JACOB QUINN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 SPRING HAVEN DR
WASHINGTON IL
61571-9792
US

IV. Provider business mailing address

104 SPRING HAVEN DR
WASHINGTON IL
61571-9792
US

V. Phone/Fax

Practice location:
  • Phone: 309-648-2399
  • Fax:
Mailing address:
  • Phone: 309-648-2399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.00912
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number096004052
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: