Healthcare Provider Details

I. General information

NPI: 1811827645
Provider Name (Legal Business Name): JILLIAN PENA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 STARBARRACK RD
RED HOOK NY
12571-2251
US

IV. Provider business mailing address

112 STARBARRACK RD
RED HOOK NY
12571-2251
US

V. Phone/Fax

Practice location:
  • Phone: 505-379-5320
  • Fax:
Mailing address:
  • Phone: 505-379-5320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number122925
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: