Healthcare Provider Details

I. General information

NPI: 1174503734
Provider Name (Legal Business Name): JACQUE DIANE YOUNG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 1ST ST
GLENWOOD IA
51534-1706
US

IV. Provider business mailing address

PO BOX 188 406 1ST STREET
GLENWOOD IA
51534-0188
US

V. Phone/Fax

Practice location:
  • Phone: 712-527-4468
  • Fax: 712-527-9458
Mailing address:
  • Phone: 712-527-4468
  • Fax: 712-527-9458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1809
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: