Healthcare Provider Details

I. General information

NPI: 1033925789
Provider Name (Legal Business Name): HOLISTIC DEVELOPMENTAL PEDS & INTEGRATIVE MED, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2024
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4940 BROADWAY STE 100
SAN ANTONIO TX
78209-5732
US

IV. Provider business mailing address

4940 BROADWAY STE 100
SAN ANTONIO TX
78209-5732
US

V. Phone/Fax

Practice location:
  • Phone: 210-403-2343
  • Fax: 210-403-2350
Mailing address:
  • Phone: 210-403-2343
  • Fax: 210-403-2350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JERI L PENKAVA
Title or Position: SOLE OWNER
Credential: MD
Phone: 210-403-2343