Provider Demographics
NPI:1962759878
Name:PENA, JENNIFER LYNN (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:PENA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9220 W SUNSET BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90069-3500
Mailing Address - Country:US
Mailing Address - Phone:310-248-4010
Mailing Address - Fax:
Practice Address - Street 1:9220 W SUNSET BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90069-3501
Practice Address - Country:US
Practice Address - Phone:310-248-4010
Practice Address - Fax:310-248-4001
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN525621363LA2100X
CANPF 12752363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1902846306OtherGROUP NPI
CAW18762OtherGROUP MEDICARE
CAGR0100430OtherGROUP MEDI-CAL