Provider Demographics
NPI:1477744662
Name:TRUCKENBROD, JAYNE SUZANNE (DO)
Entity Type:Individual
Prefix:DR
First Name:JAYNE
Middle Name:SUZANNE
Last Name:TRUCKENBROD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 RIO GRANDE ST
Mailing Address - Street 2:SUITE 340
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1137
Mailing Address - Country:US
Mailing Address - Phone:512-324-8960
Mailing Address - Fax:
Practice Address - Street 1:4900 MUELLER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3079
Practice Address - Country:US
Practice Address - Phone:512-324-0165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7718208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328476201Medicaid
TX328476203Medicaid
TX328476202Medicaid
TX317281YKYMMedicare PIN
TX328476201Medicaid
TX317281YKZJMedicare PIN