Healthcare Provider Details

I. General information

NPI: 1336830793
Provider Name (Legal Business Name): JATHAN YOUNG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W COLLEGE ST
GRAPEVINE TX
76051-3580
US

IV. Provider business mailing address

1600 W COLLEGE ST
GRAPEVINE TX
76051-3580
US

V. Phone/Fax

Practice location:
  • Phone: 817-488-7334
  • Fax:
Mailing address:
  • Phone: 817-488-7334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberW4239
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: