Provider Demographics
NPI:1477603504
Name:JI, JONATHAN YOUNG (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:YOUNG
Last Name:JI
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 1:53842 GENERATIONS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1543
Mailing Address - Country:US
Mailing Address - Phone:574-647-1069
Mailing Address - Fax:574-647-6949
Practice Address - Street 1:615 N MICHIGAN ST FL 1
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-1610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI771772084N0400X
IL0361620492084N0400X
WI212732084N0400X, 2084N0400X
IN01064532A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100181475Medicaid
IN201315870Medicaid