Provider Demographics
NPI:1538289012
Name:YOUSE, JEREMY SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:SCOTT
Last Name:YOUSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W KENYON RD STE B
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-1006
Mailing Address - Country:US
Mailing Address - Phone:217-819-3376
Mailing Address - Fax:217-729-7788
Practice Address - Street 1:1111 W KENYON RD STE B
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-1006
Practice Address - Country:US
Practice Address - Phone:217-819-3376
Practice Address - Fax:217-729-7788
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036128095207N00000X, 207ND0101X
MN49894207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN806163000Medicaid
MN806163000Medicaid