Provider Demographics
NPI:1427322668
Name:LARA PENA, JESUS JAVIER (SAS-I)
Entity type:Individual
Prefix:MR
First Name:JESUS
Middle Name:JAVIER
Last Name:LARA PENA
Suffix:
Gender:M
Credentials:SAS-I
Other - Prefix:MR
Other - First Name:JESUS
Other - Middle Name:J
Other - Last Name:LARA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-1000
Mailing Address - Country:US
Mailing Address - Phone:661-868-6600
Mailing Address - Fax:661-868-6666
Practice Address - Street 1:5121 COLLEGE AVENUE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93305
Practice Address - Country:US
Practice Address - Phone:661-868-8111
Practice Address - Fax:661-868-8087
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW6809101YA0400X
171M00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program