Provider Demographics
NPI:1962881037
Name:YOUNG, RODERICK ALEXANDER (ATC LAT)
Entity type:Individual
Prefix:MR
First Name:RODERICK
Middle Name:ALEXANDER
Last Name:YOUNG
Suffix:
Gender:M
Credentials:ATC LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 HEATHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-4707
Mailing Address - Country:US
Mailing Address - Phone:601-502-1815
Mailing Address - Fax:
Practice Address - Street 1:547 HEATHERWOOD DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39212-4707
Practice Address - Country:US
Practice Address - Phone:601-502-1815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-22
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT06452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer