Healthcare Provider Details

I. General information

NPI: 1174445365
Provider Name (Legal Business Name): LISIMBA YOUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216-4699
US

IV. Provider business mailing address

711 LAKE HARBOUR DR APT 1010
RIDGELAND MS
39157-4305
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-2000
  • Fax:
Mailing address:
  • Phone: 662-590-3993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberCP059935A
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number7979
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: