Healthcare Provider Details

I. General information

NPI: 1396096418
Provider Name (Legal Business Name): JACKIE LEE QUACH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2012
Last Update Date: 12/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 DELAWARE AVE
MARION OH
43302-6416
US

IV. Provider business mailing address

# L-3652
COLUMBUS OH
43260-6453
US

V. Phone/Fax

Practice location:
  • Phone: 740-383-8090
  • Fax: 740-375-6481
Mailing address:
  • Phone: 740-383-7927
  • Fax: 740-383-7942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA119861
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.121203
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: