1508087768 NPI number — MRS. JACQUELINE LEANNE YOUNG JACQUELINE YOUNG

Table of content: MRS. JACQUELINE LEANNE YOUNG JACQUELINE YOUNG (NPI 1508087768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508087768 NPI number — MRS. JACQUELINE LEANNE YOUNG JACQUELINE YOUNG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
JACQUELINE
Provider Middle Name:
LEANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
JACQUELINE YOUNG
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YOUNG
Provider Other First Name:
JACQUELINE
Provider Other Middle Name:
LEANNE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
JACQUELINE YOUNG
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1508087768
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
826 GOLF RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEBB CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-673-5561
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
411 MADISON
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEBB CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64870
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-673-6000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  2006029254 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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