MEDICARE: MISS JENNIFER E PENA PT, DPT

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	225100000X	Physical Therapist	PT27604	FL

General Provider Information

NPI Number	:	1114274230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JENNIFER E PENA PT, DPT

Provider Business Mailing Address
First Line	:	1425 VISCAYA PKWY
Second Line	:	SUITE 205
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-3294
Country	:	US
Telephone Number	:	239-772-2363
Fax Number	:	239-772-2365

Provider Business Practice Location Address
First Line	:	1425 VISCAYA PKWY
Second Line	:	SUITE 205
City	:	CAPE CORAL
State	:	FL
Zip	:	33990-3294
Country	:	US
Telephone Number	:	239-772-2363
Fax Number	:	239-772-2365

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

Provider Enumeration Date	:	08/08/2012
Last Update Date	:	12/14/2012

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