Provider Demographics
NPI:1427666932
Name:PENA, JACLYN
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
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 1:415 S 1ST ST STE 300
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-3800
Mailing Address - Country:US
Mailing Address - Phone:832-539-1632
Mailing Address - Fax:
Practice Address - Street 1:415 S 1ST ST STE 300
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901-3800
Practice Address - Country:US
Practice Address - Phone:832-539-1632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX388352355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant