Healthcare Provider Details

I. General information

NPI: 1831596451
Provider Name (Legal Business Name): JEFFREY YOUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2014
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CONSTITUTION AVE NE STE C
ALBUQUERQUE NM
87106-1243
US

IV. Provider business mailing address

5208 RIDGE ROCK AVE NW
ALBUQUERQUE NM
87114-4191
US

V. Phone/Fax

Practice location:
  • Phone: 505-933-0317
  • Fax:
Mailing address:
  • Phone: 505-933-0317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: