Provider Demographics
NPI:1003677899
Name:YOUNG, JORDAN TAYLOR (PMHNP)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:TAYLOR
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PMHNP
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 353
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-0353
Mailing Address - Country:US
Mailing Address - Phone:607-345-0824
Mailing Address - Fax:
Practice Address - Street 1:4811 BUCKLEY RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3676
Practice Address - Country:US
Practice Address - Phone:315-457-9966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY798974163WP0808X
NYF405880363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health