Healthcare Provider Details

I. General information

NPI: 1942965983
Provider Name (Legal Business Name): JERRY YOUNG DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2021
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12465 LEWIS ST STE 101
GARDEN GROVE CA
92840-4658
US

IV. Provider business mailing address

12465 LEWIS ST STE 101
GARDEN GROVE CA
92840-4658
US

V. Phone/Fax

Practice location:
  • Phone: 714-703-8477
  • Fax: 714-703-8157
Mailing address:
  • Phone: 714-703-8477
  • Fax: 714-703-8157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT300887
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: