Provider Demographics
NPI:1073513008
Name:YOUNG, LISA JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JACKSON
Last Name:YOUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:DEPT 960
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-763-0200
Mailing Address - Fax:901-260-1713
Practice Address - Street 1:7460 WOLF RIVER BOULEVARD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-763-0200
Practice Address - Fax:901-260-1713
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38424207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01575895Medicaid
TN3891911Medicaid
TN4270159OtherBCBS
AR154284001Medicaid
TNP00882938OtherRAILROAD MEDICARE
TNP00882938OtherRAILROAD MEDICARE
TN3891911Medicaid