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 1:6210 E HWY 290
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1142
Mailing Address - Country:US
Mailing Address - Phone:512-483-9596
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:22420 IH 35 STE 203
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-2656
Practice Address - Country:US
Practice Address - Phone:737-404-0347
Practice Address - Fax:512-406-6295
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV0573207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine