Provider Demographics
NPI:1780970780
Name:YOUNG, JELYN BERNARDO (PHD)
Entity type:Individual
Prefix:DR
First Name:JELYN
Middle Name:BERNARDO
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17734 HUNTING BOW CIR STE 101
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-5383
Mailing Address - Country:US
Mailing Address - Phone:813-443-5311
Mailing Address - Fax:
Practice Address - Street 1:17734 HUNTING BOW CIR STE 101
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-5383
Practice Address - Country:US
Practice Address - Phone:619-920-4629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
FLPY10002103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)