Healthcare Provider Details

I. General information

NPI: 1336090190
Provider Name (Legal Business Name): JACQUELINE JADE YOUNG FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2026
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 500 W BLDG C
PROVO UT
84604-3305
US

IV. Provider business mailing address

1055 N 500 W
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 920-903-4555
  • Fax:
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13344666-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number13344666-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: