Basic Information
Provider Information | |||||||||
NPI: | 1588671481 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALTH AND HUMAN SERVICES COMMISSION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KERRVILLE STATE HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4110 GUADALUPE ST | ||||||||
Address2: |   | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787514223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5122065011 | ||||||||
FaxNumber: | 5122065302 | ||||||||
Practice Location | |||||||||
Address1: | 721 THOMPSON DRIVE | ||||||||
Address2: |   | ||||||||
City: | KERRVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 780285154 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8308962211 | ||||||||
FaxNumber: | 8308962373 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2006 | ||||||||
LastUpdateDate: | 08/25/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JOHNSON | ||||||||
AuthorizedOfficialFirstName: | JANA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ACCOUNTANT III | ||||||||
AuthorizedOfficialTelephone: | 5122065284 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X |   | TX | N | 193200000X MULTI-SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist |   | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RE0101X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 2084F0202X |   | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Forensic Psychiatry | 2084P0800X |   | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0805X |   | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 2084P0804X |   | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 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 |   | 364SP0808X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 208D00000X |   | TX | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   | 103TC0700X |   | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
ID | Type | State | Issuer | Description | HH4631 | 01 | TX | BCBS PSYCHIATRIC | OTHER | 1081028-01 | 05 | TX |   | MEDICAID | 1273203-02 | 05 | TX |   | MEDICAID | HH3002 | 01 | TX | BCBS DRUG/ALCOHOL | OTHER | 1081028-02 | 05 | TX |   | MEDICAID | 1273203-03 | 05 | TX |   | MEDICAID | 4540185 | 01 | TX | PHARMACY NCPDP NUMBER | OTHER |