Provider Demographics
NPI:1417616574
Name:YOUNG, JONIQUE
Entity Type:Individual
Prefix:MRS
First Name:JONIQUE
Middle Name:
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 1:200 HENSLEY AVE BLDG 1620
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76127-1040
Mailing Address - Country:US
Mailing Address - Phone:817-709-0762
Mailing Address - Fax:
Practice Address - Street 1:200 HENSLEY AVE BLDG 1670
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76127-1040
Practice Address - Country:US
Practice Address - Phone:817-852-3295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490197891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149019789OtherMILITARY/ FEDERAL WORKER