Provider Demographics
NPI:1588875488
Name:YOUNG, GLORIA JEAN (PT)
Entity type:Individual
Prefix:DR
First Name:GLORIA
Middle Name:JEAN
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 77148
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-7148
Mailing Address - Country:US
Mailing Address - Phone:205-567-4196
Mailing Address - Fax:904-619-5622
Practice Address - Street 1:4501 CAPPER RD. #A212
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-7148
Practice Address - Country:US
Practice Address - Phone:205-567-4196
Practice Address - Fax:904-619-5622
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT10019171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor