Healthcare Provider Details

I. General information

NPI: 1477744662
Provider Name (Legal Business Name): JAYNE SUZANNE TRUCKENBROD DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 MUELLER BLVD
AUSTIN TX
78723-3079
US

IV. Provider business mailing address

1601 RIO GRANDE ST SUITE 340
AUSTIN TX
78701-1137
US

V. Phone/Fax

Practice location:
  • Phone: 512-324-0165
  • Fax:
Mailing address:
  • Phone: 512-324-8960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberP7718
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP7718
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: