Provider Demographics
NPI:1154773414
Name:YOUNG, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2331 PEPPERMILL CT
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48353-3146
Mailing Address - Country:US
Mailing Address - Phone:248-707-4796
Mailing Address - Fax:
Practice Address - Street 1:2331 PEPPERMILL CT
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:MI
Practice Address - Zip Code:48353-3146
Practice Address - Country:US
Practice Address - Phone:248-707-4796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIY520439676427247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other