Provider Demographics
NPI:1609005628
Name:JELINEK, MARY AMANDA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:AMANDA
Last Name:JELINEK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 3041
Mailing Address - Street 2:
Mailing Address - City:MARBLE FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:78654-3077
Mailing Address - Country:US
Mailing Address - Phone:512-710-0551
Mailing Address - Fax:512-717-6337
Practice Address - Street 1:5524 BEE CAVES RD STE H2
Practice Address - Street 2:
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746-5246
Practice Address - Country:US
Practice Address - Phone:512-710-0551
Practice Address - Fax:512-717-6337
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-12
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34920103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX293738502Medicaid