Provider Demographics
NPI:1659762573
Name:YOUNG, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
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 1:8887 CR 647S
Mailing Address - Street 2:
Mailing Address - City:BUSHNELL
Mailing Address - State:FL
Mailing Address - Zip Code:33513-7435
Mailing Address - Country:US
Mailing Address - Phone:813-252-0813
Mailing Address - Fax:
Practice Address - Street 1:8887 CR 647S
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-7435
Practice Address - Country:US
Practice Address - Phone:813-252-0813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-13
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
FLADC-010479-2015101YA0400X
FLMH13395101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)