Provider Demographics
NPI:1548786320
Name:PENA, MELISSA JASMINE (LMFT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JASMINE
Last Name:PENA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-0510
Mailing Address - Country:US
Mailing Address - Phone:209-550-5869
Mailing Address - Fax:
Practice Address - Street 1:100 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354
Practice Address - Country:US
Practice Address - Phone:209-550-5869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT142512106H00000X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional