Healthcare Provider Details

I. General information

NPI: 1184960403
Provider Name (Legal Business Name): JEREMY JAMES PENE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2012
Last Update Date: 04/11/2026
Certification Date: 04/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6546 E 2ND ST STE C
PRESCOTT VALLEY AZ
86314-3540
US

IV. Provider business mailing address

3165 STILLWATER DR
PRESCOTT AZ
86305-7173
US

V. Phone/Fax

Practice location:
  • Phone: 928-327-9528
  • Fax: 928-327-7428
Mailing address:
  • Phone: 928-277-0875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number603362
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number322104
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: