Provider Demographics
NPI:1225776602
Name:PENA DIAZ, JELEN
Entity Type:Individual
Prefix:
First Name:JELEN
Middle Name:
Last Name:PENA DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 NW 87TH AVE UNIT 334
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2789
Mailing Address - Country:US
Mailing Address - Phone:786-405-6110
Mailing Address - Fax:
Practice Address - Street 1:1905 NW 82ND AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1011
Practice Address - Country:US
Practice Address - Phone:786-420-5924
Practice Address - Fax:786-542-5340
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-25
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health