Basic Information
| Provider Information | |||||||||
| NPI: | 1609005628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JELINEK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | AMANDA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSY.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4749 WILLIAMS DR | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | GEORGETOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786333710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128093141 | ||||||||
| FaxNumber: | 2546169487 | ||||||||
| Practice Location | |||||||||
| Address1: | 5524 BEE CAVES ROAD, SUITE K4 | ||||||||
| Address2: | |||||||||
| City: | WEST LAKE HILLS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787467874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5127100551 | ||||||||
| FaxNumber: | 5127176337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2009 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 34902 | TX | Y | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.