Provider Demographics
NPI:1417291881
Name:PENA, JEANINE (LMT)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 LAKELAND AVE APT F5
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-1918
Mailing Address - Country:US
Mailing Address - Phone:516-641-4998
Mailing Address - Fax:
Practice Address - Street 1:375 E MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8418
Practice Address - Country:US
Practice Address - Phone:516-641-4998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-25
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025820225700000X
NY005017171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist