Provider Demographics
NPI:1114946712
Name:YOUNG, JEFFRY JAMES (DO)
Entity type:Individual
Prefix:
First Name:JEFFRY
Middle Name:JAMES
Last Name:YOUNG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:920-288-5500
Mailing Address - Fax:920-288-5510
Practice Address - Street 1:1160 KEPLER DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8321
Practice Address - Country:US
Practice Address - Phone:920-288-5500
Practice Address - Fax:920-288-5510
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31970208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30049900Medicaid
E85817Medicare UPIN
07125-0117Medicare ID - Type Unspecified