Provider Demographics
NPI:1578807749
Name:PENA, JESSICA (PHD MS MED LPCA)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:PENA
Suffix:
Gender:F
Credentials:PHD MS MED LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 MILLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-1298
Mailing Address - Country:US
Mailing Address - Phone:803-406-5442
Mailing Address - Fax:
Practice Address - Street 1:2805 MILLWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-1298
Practice Address - Country:US
Practice Address - Phone:803-406-5442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-12
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5726103T00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS1420Medicaid
SC5723OtherLP
SC5726OtherSC