Basic Information
| Provider Information | |||||||||
| NPI: | 1043314263 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTH AND HUMAN SERVICES COMMISSION | ||||||||
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| OtherOrganizationName: | NORTH TEXAS STATE HOSPITAL/VERNON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4110 GUADALUPE ST | ||||||||
| Address2: | MC-2023 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787514296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122065284 | ||||||||
| FaxNumber: | 5122065302 | ||||||||
| Practice Location | |||||||||
| Address1: | 4730 COLLEGE DRIVE | ||||||||
| Address2: | |||||||||
| City: | VERNON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763844009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9405529901 | ||||||||
| FaxNumber: | 9405532523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2006 | ||||||||
| LastUpdateDate: | 08/25/2017 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ACCOUNTANT III | ||||||||
| AuthorizedOfficialTelephone: | 5122065284 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TF0200X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Forensic | 183500000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist | 2084F0202X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Forensic Psychiatry | 208D00000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 363A00000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364S00000X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | 2084P0800X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0805X | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 103G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 1081036-01 | 05 | TX | MEDICAID | HH4008 | 01 | TX | BCBS FORENSIC | OTHER | 1301640-07 | 05 | TX | MEDICAID | 1081036-02 | 05 | TX | MEDICAID | 4539219 | 01 | TX | PHARMACY NCPDP NUMBER | OTHER | 0211963-01 | 05 | TX | MEDICAID | HH3011 | 01 | TX | BCBS ADOLESCENT | OTHER |