Provider Demographics
NPI:1902200108
Name:YOUNG, JESSICA (LPC, CMHIMP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LPC, CMHIMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 252
Mailing Address - Street 2:
Mailing Address - City:WALWORTH
Mailing Address - State:WI
Mailing Address - Zip Code:53184
Mailing Address - Country:US
Mailing Address - Phone:262-607-2770
Mailing Address - Fax:
Practice Address - Street 1:129 KENOSHA ST
Practice Address - Street 2:
Practice Address - City:WALWORTH
Practice Address - State:WI
Practice Address - Zip Code:53184
Practice Address - Country:US
Practice Address - Phone:262-607-2770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5479-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional