Provider Demographics
NPI:1972731032
Name:JACQUE DESHAY YOUNG, PLLC
Entity type:Organization
Organization Name:JACQUE DESHAY YOUNG, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUE
Authorized Official - Middle Name:DESHAY
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:502-644-4068
Mailing Address - Street 1:PO BOX 16353
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40256-0353
Mailing Address - Country:US
Mailing Address - Phone:502-644-4068
Mailing Address - Fax:
Practice Address - Street 1:4242 DANNY DR
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-9363
Practice Address - Country:US
Practice Address - Phone:502-644-4068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5867P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1972731032OtherNPI
1639315443OtherNPI