Provider Demographics
NPI:1104136498
Name:YOUNG, JACQUELYN SUE (LMT)
Entity type:Individual
Prefix:MISS
First Name:JACQUELYN
Middle Name:SUE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-1764
Mailing Address - Country:US
Mailing Address - Phone:330-334-1056
Mailing Address - Fax:
Practice Address - Street 1:242 E MILLTOWN RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-1246
Practice Address - Country:US
Practice Address - Phone:330-345-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.019074225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist