1386650224 NPI number — JENNIFER DARA YOUNG MC, LPC

Table of content: JENNIFER DARA YOUNG MC, LPC (NPI 1386650224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386650224 NPI number — JENNIFER DARA YOUNG MC, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
JENNIFER
Provider Middle Name:
DARA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MC, LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAULFAIR
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
DARA
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1386650224
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4901 W BELL RD
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85308-3465
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-978-0945
Provider Business Mailing Address Fax Number:
602-843-8028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4901 W BELL RD
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85308-3465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-978-0945
Provider Business Practice Location Address Fax Number:
602-843-8028
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPC - 2425 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 757750 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 506812 . This is a "MHS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: MHN . This is a "308122" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 252952 . This is a "COMPSYCH" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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