Provider Demographics
NPI:1477964625
Name:PENA, VANESSA ILEANA (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:ILEANA
Last Name:PENA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 SPRING PARK RD STE 102
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5989
Mailing Address - Country:US
Mailing Address - Phone:904-694-2800
Mailing Address - Fax:904-515-5587
Practice Address - Street 1:5600 SPRING PARK RD STE 102
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5989
Practice Address - Country:US
Practice Address - Phone:305-301-4870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-09
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13217235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist