Provider Demographics
NPI:1760887178
Name:YOUNG, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:MAE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10546 CLAIRDOAN AVE 44108
Mailing Address - Street 2:3635 E. 61ST 44105
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108
Mailing Address - Country:US
Mailing Address - Phone:216-322-3818
Mailing Address - Fax:
Practice Address - Street 1:10546 CLAIRDOAN AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-1310
Practice Address - Country:US
Practice Address - Phone:216-322-3818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400110640402376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0108206Medicaid