Provider Demographics
NPI:1760171268
Name:YOUNGER, JOHN CLARK
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CLARK
Last Name:YOUNGER
Suffix:
Gender:M
Credentials:
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 1152
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-1152
Mailing Address - Country:US
Mailing Address - Phone:985-200-3999
Mailing Address - Fax:
Practice Address - Street 1:19344 N 10TH ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-8877
Practice Address - Country:US
Practice Address - Phone:985-200-3999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACIT-5517101YA0400X
LAPLC9395101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)