Provider Demographics
NPI:1063447308
Name:FORSBERG, JENNIFER ANN (PHD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:FORSBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11211 TAYLOR DRAPER LN
Mailing Address - Street 2:STE 202
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-3916
Mailing Address - Country:US
Mailing Address - Phone:572-343-8850
Mailing Address - Fax:572-343-8079
Practice Address - Street 1:11211 TAYLOR DRAPER LN
Practice Address - Street 2:STE 202
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-3916
Practice Address - Country:US
Practice Address - Phone:572-343-8850
Practice Address - Fax:572-343-8079
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32478103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX079974401Medicaid
Q32433Medicare UPIN
TX079974401Medicaid