Provider Demographics
NPI:1245651058
Name:YOUNG, JEANELLE
Entity type:Individual
Prefix:
First Name:JEANELLE
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEANELLE
Other - Middle Name:
Other - Last Name:JAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:515 S 700 E STE 2A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2855
Mailing Address - Country:US
Mailing Address - Phone:801-935-4171
Mailing Address - Fax:801-935-4946
Practice Address - Street 1:515 S 700 E STE 2A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2855
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:801-935-4946
Is Sole Proprietor?:No
Enumeration Date:2013-12-20
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-13-14505103K00000X
UT11703583-2506103K00000X
UT11703538-2506103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst