MEDICARE: DR. JACQUELINE MARY QUINN-TAN PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	20041167A	IN

General Provider Information

NPI Number	:	1518111996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUELINE MARY QUINN-TAN PSY.D.

Provider Business Mailing Address
First Line	:	1540 TRINITY PL
Second Line	:
City	:	MISHAWAKA
State	:	IN
Zip	:	46545-5006
Country	:	US
Telephone Number	:	574-272-9000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 S MICHIGAN ST
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46601-3426
Country	:	US
Telephone Number	:	574-235-5408
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2008
Last Update Date	:	08/25/2021

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