Provider Demographics
NPI:1164004693
Name:VONGPRATHOUM, JENNEY (MD)
Entity Type:Individual
Prefix:
First Name:JENNEY
Middle Name:
Last Name:VONGPRATHOUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N INTERSTATE 35 STE C2.410
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N INTERSTATE 35 STE C2.410
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1926
Practice Address - Country:US
Practice Address - Phone:512-324-7318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10076144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine