Provider Demographics
NPI:1063100311
Name:PENA, JAQUELYN (OD)
Entity type:Individual
Prefix:
First Name:JAQUELYN
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:VEGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2188 STATE HIGHWAY 46 W STE 102
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78132-4467
Mailing Address - Country:US
Mailing Address - Phone:830-302-3357
Mailing Address - Fax:830-302-3358
Practice Address - Street 1:2188 STATE HIGHWAY 46 W STE 102
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78132-4467
Practice Address - Country:US
Practice Address - Phone:830-302-3357
Practice Address - Fax:830-302-3358
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX11109152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program