Provider Demographics
NPI:1316039779
Name:PENALOZA, JILL MARIE (LCPAT, CGP)
Entity Type:Individual
Prefix:MS
First Name:JILL
Middle Name:MARIE
Last Name:PENALOZA
Suffix:
Gender:F
Credentials:LCPAT, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 CHESAPEAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-3305
Mailing Address - Country:US
Mailing Address - Phone:410-279-3106
Mailing Address - Fax:
Practice Address - Street 1:127 CHESAPEAKE AVE
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-2607
Practice Address - Country:US
Practice Address - Phone:410-279-3106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDATC022101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherJILL PENALOZA