Provider Demographics
NPI:1124258645
Name:PENAGALURI, JAYA PRAVEEN KUMAR
Entity type:Individual
Prefix:
First Name:JAYA PRAVEEN
Middle Name:KUMAR
Last Name:PENAGALURI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 W 8TH AVE STE 450E
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2302
Mailing Address - Country:US
Mailing Address - Phone:509-474-6920
Mailing Address - Fax:
Practice Address - Street 1:105 W 8TH AVE STE 450E
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2302
Practice Address - Country:US
Practice Address - Phone:509-474-6920
Practice Address - Fax:509-474-3014
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-17
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM138302084P0800X
MDD784152084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry