Basic Information
| Provider Information | |||||||||
| NPI: | 1346475753 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAY | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | SIMPSON | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 W 38TH ST | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787316400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123243315 | ||||||||
| FaxNumber: | 5123243314 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 W 38TH ST | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787316400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123243315 | ||||||||
| FaxNumber: | 5123243314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2009 | ||||||||
| LastUpdateDate: | 12/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 34163 | TX | N | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC2200X | 34163 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
ID Information
| ID | Type | State | Issuer | Description | 88075A | 01 | TX | BCBS | OTHER | 217415301 | 05 | TX | MEDICAID |