Healthcare Provider Details

I. General information

NPI: 1548144504
Provider Name (Legal Business Name): JACQUELINE PENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 08/04/2025
Certification Date: 08/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7850 JEFFERSON ST NE STE 300
ALBUQUERQUE NM
87109-4314
US

IV. Provider business mailing address

5908 SWEETWATER DR NW
ALBUQUERQUE NM
87120-2244
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-1114
  • Fax:
Mailing address:
  • Phone: 505-934-5135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: