Provider Demographics
NPI:1194817452
Name:YOUNG, MARY J
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:J
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 17221
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403
Mailing Address - Country:US
Mailing Address - Phone:870-268-1777
Mailing Address - Fax:870-268-1777
Practice Address - Street 1:2213 EAST HIGHLAND DRIVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-268-1777
Practice Address - Fax:870-268-1777
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5821200001Medicare NSC