Provider Demographics
NPI:1215596382
Name:YOUNG, JENEBA SYLVIA
Entity Type:Individual
Prefix:
First Name:JENEBA
Middle Name:SYLVIA
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12099 W WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-5882
Mailing Address - Country:US
Mailing Address - Phone:818-415-5747
Mailing Address - Fax:
Practice Address - Street 1:1611 S PACIFIC COAST HWY STE 307
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-5614
Practice Address - Country:US
Practice Address - Phone:424-226-6172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA121338106H00000X
171M00000X, 390200000X
CA138611106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program