MEDICARE: JASMINE JAE PENA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	101764	TX

General Provider Information

NPI Number	:	1063353498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASMINE JAE PENA

Provider Business Mailing Address
First Line	:	5424 AVENUE A
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79404-4526
Country	:	US
Telephone Number	:	806-559-3793
Fax Number	:

Provider Business Practice Location Address
First Line	:	3131 EXECUTIVE DR
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-6801
Country	:	US
Telephone Number	:	325-234-5264
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2026
Last Update Date	:	04/02/2026

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