Healthcare Provider Details

I. General information

NPI: 1336894930
Provider Name (Legal Business Name): ESTRELLA JANE A. PENA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANE PENA PT

II. Dates (important events)

Enumeration Date: 02/14/2022
Last Update Date: 02/14/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PENNEY FARMS 3 PAVILLION PLACE 3495 HOFFMAN ST
GREEN COVE SPRINGS FL
32043
US

IV. Provider business mailing address

787 BELLSHIRE DR
ORANGE PARK FL
32065-2220
US

V. Phone/Fax

Practice location:
  • Phone: 904-284-8200
  • Fax:
Mailing address:
  • Phone: 904-476-5365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10723
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: