Healthcare Provider Details

I. General information

NPI: 1134369093
Provider Name (Legal Business Name): JEAN ANDERSON DUNHAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2009
Last Update Date: 12/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 W RIVERSIDE DR
AUSTIN TX
78704-1247
US

IV. Provider business mailing address

1430 COLLIER ST
AUSTIN TX
78704-2911
US

V. Phone/Fax

Practice location:
  • Phone: 512-804-3000
  • Fax: 512-323-9544
Mailing address:
  • Phone: 512-472-4357
  • Fax: 512-703-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberP6156
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: