Provider Demographics
NPI:1003203274
Name:YOUNG, JENNIFER SUE (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SUE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1300 CREASON RD
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:AR
Mailing Address - Zip Code:72422-1716
Mailing Address - Country:US
Mailing Address - Phone:870-857-3399
Mailing Address - Fax:
Practice Address - Street 1:1300 CREASON RD
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:AR
Practice Address - Zip Code:72422-1716
Practice Address - Country:US
Practice Address - Phone:870-857-3399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004391363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR209603758Medicaid
AR422254YJA8Medicare Oscar/Certification