Active NPI
Jahn Quattlebaum
- Mental Health Counselor
- Tyler, TX
National Provider Identifier
1821577628
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- 71752
- Practice address
- 6200 Wilshire Dr
Tyler, TX 75703-4159 - Phone
- (903) 216-6641
- NPI assigned
- Aug 13, 2018
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Addiction (Substance Use Disorder) Counselor | 101YA0400X | 12272 | TX | |
| Mental Health Counselor | 101YM0800X | LPC.0014807 | CO | |
| Mental Health Counselor | 101YM0800X | 71752 | TX | Primary |
Addresses
Primary practice location
6200 Wilshire Dr
Tyler, TX 75703-4159
Mailing address
6200 Wilshire Dr
Tyler, TX 75703-4159
Phone (903) 216-6641
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 12272 | TX | MD | Addiction (Substance Use Disorder) Counselor |
| LPC.0014807 | CO | MD | Mental Health Counselor |
| 71752 | TX | MD | Mental Health Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1534118400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1534118400000",
"number": "1821577628",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "6200 WILSHIRE DR",
"city": "TYLER",
"state": "TX",
"postal_code": "757034159",
"telephone_number": "903-216-6641"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6200 WILSHIRE DR",
"city": "TYLER",
"state": "TX",
"postal_code": "757034159",
"telephone_number": "903-216-6641"
}
],
"practiceLocations": [],
"basic": {
"last_name": "QUATTLEBAUM",
"first_name": "JAHN",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2018-08-13",
"last_updated": "2018-08-13",
"status": "A"
},
"taxonomies": [
{
"code": "101YA0400X",
"taxonomy_group": "",
"desc": "Counselor, Addiction (Substance Use Disorder)",
"state": "TX",
"license": "12272",
"primary": false
},
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "CO",
"license": "LPC.0014807",
"primary": false
},
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "TX",
"license": "71752",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Tyler, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 13, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.