Provider Demographics
NPI:1114274230
Name:PENA, JENNIFER E (PT, DPT)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:E
Last Name:PENA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 VISCAYA PKWY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-3294
Mailing Address - Country:US
Mailing Address - Phone:239-772-2363
Mailing Address - Fax:239-772-2365
Practice Address - Street 1:1425 VISCAYA PKWY
Practice Address - Street 2:SUITE 205
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-3294
Practice Address - Country:US
Practice Address - Phone:239-772-2363
Practice Address - Fax:239-772-2365
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT27604225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist