Provider Demographics
NPI:1326517137
Name:YOUNG, JANENE DESIREE
Entity Type:Individual
Prefix:
First Name:JANENE
Middle Name:DESIREE
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 1:1475 COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48040-1617
Mailing Address - Country:US
Mailing Address - Phone:810-987-1258
Mailing Address - Fax:
Practice Address - Street 1:1406 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5804
Practice Address - Country:US
Practice Address - Phone:810-987-1258
Practice Address - Fax:810-987-3505
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MI6451018584101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator