Basic Information
Provider Information | |||||||||
NPI: | 1477744662 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TRUCKENBROD | ||||||||
FirstName: | JAYNE | ||||||||
MiddleName: | SUZANNE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1601 RIO GRANDE ST | ||||||||
Address2: | SUITE 340 | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787011137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5123248960 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4900 MUELLER BLVD | ||||||||
Address2: |   | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787233079 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5123240165 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2007 | ||||||||
LastUpdateDate: | 10/15/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | P7718 | TX | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208000000X | P7718 | TX | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 328476201 | 05 | TX |   | MEDICAID | 328476203 | 05 | TX |   | MEDICAID | 328476202 | 05 | TX |   | MEDICAID |