Healthcare Provider Details

I. General information

NPI: 1871990234
Provider Name (Legal Business Name): JENNIFER PENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 SIERRA DR
MODESTO CA
95351-3254
US

IV. Provider business mailing address

100 POPLAR AVE
MODESTO CA
95354-0510
US

V. Phone/Fax

Practice location:
  • Phone: 209-492-9785
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW60358
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: