Healthcare Provider Details

I. General information

NPI: 1730997826
Provider Name (Legal Business Name): JONATHAN JAMES PENA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2024
Last Update Date: 12/21/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27700 MEDICAL CENTER RD
MISSION VIEJO CA
92691-6426
US

IV. Provider business mailing address

322 GULF STREAM WAY
COSTA MESA CA
92627-2285
US

V. Phone/Fax

Practice location:
  • Phone: 949-364-1400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number302648
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: