Healthcare Provider Details

I. General information

NPI: 1104246818
Provider Name (Legal Business Name): JORGE PENA CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 1ST AVE SE STE 104
CEDAR RAPIDS IA
52402-3221
US

IV. Provider business mailing address

4403 1ST AVE SE STE 104
CEDAR RAPIDS IA
52402-3221
US

V. Phone/Fax

Practice location:
  • Phone: 319-423-0919
  • Fax:
Mailing address:
  • Phone: 319-423-0919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1370
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: