Provider Demographics
NPI:1184178188
Name:YOUNGBLOOD, JOHN OWEN III (MS, LAT, ATC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:OWEN
Last Name:YOUNGBLOOD
Suffix:III
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 MERCER UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31207-1515
Mailing Address - Country:US
Mailing Address - Phone:478-955-1587
Mailing Address - Fax:
Practice Address - Street 1:1501 MERCER UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31207-1515
Practice Address - Country:US
Practice Address - Phone:478-955-1587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0021232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer