Provider Demographics
NPI:1336830793
Name:YOUNG, JATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JATHAN
Middle Name:
Last Name:YOUNG
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 1:1522 SIMPSON ROAD EAST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-5718
Mailing Address - Country:US
Mailing Address - Phone:734-764-5173
Mailing Address - Fax:
Practice Address - Street 1:3399 E GRAND RIVER AVE STE 202
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-7555
Practice Address - Country:US
Practice Address - Phone:734-539-5080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351050504390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program