Provider Demographics
NPI:1487604765
Name:YOUNGSTROM, JENNIFER K (PHD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:YOUNGSTROM
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 1:103 WESTCHESTER PL
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-5237
Mailing Address - Country:US
Mailing Address - Phone:216-410-5711
Mailing Address - Fax:
Practice Address - Street 1:1316 BROAD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3533
Practice Address - Country:US
Practice Address - Phone:216-410-5711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3287103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000210278OtherANTHEM BLUE CROSS PIN