Provider Demographics
NPI:1083924179
Name:YOUNG, JEANETTE MARY (OT)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:MARY
Last Name:YOUNG
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3731 6TH AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4383
Mailing Address - Country:US
Mailing Address - Phone:619-291-3515
Mailing Address - Fax:619-261-3529
Practice Address - Street 1:3731 6TH AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4383
Practice Address - Country:US
Practice Address - Phone:619-291-3515
Practice Address - Fax:619-261-3529
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11396225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist