Provider Demographics
NPI:1124051057
Name:SELBY, JEANNE C (PHD)
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:C
Last Name:SELBY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:E
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1705 WOODBURY
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-5279
Mailing Address - Country:US
Mailing Address - Phone:214-762-8079
Mailing Address - Fax:972-820-9711
Practice Address - Street 1:2340 E TRINITY MILLS RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-1942
Practice Address - Country:US
Practice Address - Phone:214-762-8079
Practice Address - Fax:972-820-9711
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31083103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
7192856OtherAETNA
0072PQOtherBLUE CROSS BLUE SHIELD (BCBS)
396566OtherMANAGED HEALTH NETWORK (MHN)
TX157554007Medicaid
396566OtherMANAGED HEALTH NETWORK (MHN)