Provider Demographics
NPI:1386795045
Name:PENA, JENNIFER K
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:PENA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 N SUNVALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-3801
Mailing Address - Country:US
Mailing Address - Phone:480-472-5451
Mailing Address - Fax:480-472-3999
Practice Address - Street 1:1025 N COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3307
Practice Address - Country:US
Practice Address - Phone:480-472-0727
Practice Address - Fax:480-472-0705
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0834235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ711798Medicaid