Provider Demographics
NPI:1174503734
Name:YOUNG, JACQUE DIANE (OD)
Entity type:Individual
Prefix:
First Name:JACQUE
Middle Name:DIANE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:406 1ST STREET
Mailing Address - City:GLENWOOD
Mailing Address - State:IA
Mailing Address - Zip Code:51534-0188
Mailing Address - Country:US
Mailing Address - Phone:712-527-4468
Mailing Address - Fax:712-527-9458
Practice Address - Street 1:406 1ST ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IA
Practice Address - Zip Code:51534-1706
Practice Address - Country:US
Practice Address - Phone:712-527-4468
Practice Address - Fax:712-527-9458
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1809152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA410015491OtherRAILROAD MEDICARE
IA0038547Medicaid
IA24626Medicare ID - Type Unspecified
IA0038547Medicaid
IA410015491OtherRAILROAD MEDICARE