Healthcare Provider Details

I. General information

NPI: 1295298545
Provider Name (Legal Business Name): JOVAHNA PENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 04/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BEHAVIORAL HEALTH GROUP 850 23RD AVE UNIT A
LONGMONT CO
80501
US

IV. Provider business mailing address

1906 PEARL ST APT 4
BOULDER CO
80302-4472
US

V. Phone/Fax

Practice location:
  • Phone: 303-245-0123
  • Fax:
Mailing address:
  • Phone: 928-606-4353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0107861
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: