Provider Demographics
NPI:1780892448
Name:YOUNG, JEFFREY (PHD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:YOUNG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15108 DEL GADO DR
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-4436
Mailing Address - Country:US
Mailing Address - Phone:818-905-7121
Mailing Address - Fax:818-386-9321
Practice Address - Street 1:16550 VENTURA BLVD
Practice Address - Street 2:SUITE 405
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2004
Practice Address - Country:US
Practice Address - Phone:818-905-7121
Practice Address - Fax:818-386-9321
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15577103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP15577Medicare ID - Type UnspecifiedPSYCHOLOGIST