Provider Demographics
NPI:1720809593
Name:YOUNG, JENNA ELIZABETH ROSE (LMT)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:ELIZABETH ROSE
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 1:22 VAN BUREN ST
Mailing Address - Street 2:APT 1
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094
Mailing Address - Country:US
Mailing Address - Phone:716-248-0691
Mailing Address - Fax:
Practice Address - Street 1:8201 MAIN ST
Practice Address - Street 2:SUITE 7
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-970-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033744-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist