Provider Demographics
NPI:1679921001
Name:PENA, JESUS M
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:M
Last Name:PENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CENTENNIAL DR
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-7938
Mailing Address - Country:US
Mailing Address - Phone:978-535-1110
Mailing Address - Fax:978-535-2907
Practice Address - Street 1:10 CENTENNIAL DR
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-7938
Practice Address - Country:US
Practice Address - Phone:978-535-1110
Practice Address - Fax:978-535-2907
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-26
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program