Provider Demographics
NPI:1003831082
Name:PENA, JOSE CARLOS (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:CARLOS
Last Name:PENA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 BANCROFT ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-5122
Mailing Address - Country:US
Mailing Address - Phone:619-282-3822
Mailing Address - Fax:619-563-3913
Practice Address - Street 1:4550 KEARNY VILLA RD
Practice Address - Street 2:SUITE 116
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1578
Practice Address - Country:US
Practice Address - Phone:858-279-1223
Practice Address - Fax:858-279-6154
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13353103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical