MEDICARE: JACOB YOUNG DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5501017310	OTHER	MI	STATE LICENSE

General Provider Information

NPI Number	:	1699152645
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB YOUNG DPT

Provider Business Mailing Address
First Line	:	5620 BLOOMFIELD DR
Second Line	:
City	:	MIDLAND
State	:	MI
Zip	:	48642-3272
Country	:	US
Telephone Number	:	734-652-7777
Fax Number	:

Provider Business Practice Location Address
First Line	:	5460 W ROLLING HILLS DR
Second Line	:
City	:	BRIDGEPORT
State	:	MI
Zip	:	48722-9668
Country	:	US
Telephone Number	:	989-272-4500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2015
Last Update Date	:	10/09/2023

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