Provider Demographics
NPI:1114225588
Name:YOUNG, JOHN RUSSELL (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RUSSELL
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 N SHORE PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-6383
Mailing Address - Country:US
Mailing Address - Phone:601-829-0505
Mailing Address - Fax:601-829-0506
Practice Address - Street 1:1220 N SHORE PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-6383
Practice Address - Country:US
Practice Address - Phone:601-829-0505
Practice Address - Fax:601-829-0506
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT4732225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist