Provider Demographics
NPI:1891835484
Name:NICKSON-YOUNG, JACQUELINE DENISE (GNP-BC, APMHNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:DENISE
Last Name:NICKSON-YOUNG
Suffix:
Gender:F
Credentials:GNP-BC, APMHNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 N HAMPTON RD # 303
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-4920
Mailing Address - Country:US
Mailing Address - Phone:469-734-4990
Mailing Address - Fax:972-255-3958
Practice Address - Street 1:512 N HAMPTON RD # 303
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-4920
Practice Address - Country:US
Practice Address - Phone:469-734-4990
Practice Address - Fax:972-255-3958
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX568271363LG0600X
TXAPRN LICENSE NO: AP1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87N197Medicare ID - Type Unspecified
TXS70870Medicare UPIN