Provider Demographics
NPI:1750377578
Name:YOUNG, JAMES OLIN JR (CP,FAAOP)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:OLIN
Last Name:YOUNG
Suffix:JR
Gender:M
Credentials:CP,FAAOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 20TH ST E
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3645
Mailing Address - Country:US
Mailing Address - Phone:229-387-6600
Mailing Address - Fax:229-387-7800
Practice Address - Street 1:4900 MERCER UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-6239
Practice Address - Country:US
Practice Address - Phone:478-474-5678
Practice Address - Fax:478-474-5018
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACP0029101744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA408774069AMedicaid
GA610057500OtherWORKERS COMPENSATION
GA408774069AMedicaid