Provider Demographics
NPI:1922609478
Name:PENALOZA, JONATHAN L
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:L
Last Name:PENALOZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 H ST APT 3
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-4060
Mailing Address - Country:US
Mailing Address - Phone:916-240-1668
Mailing Address - Fax:
Practice Address - Street 1:930 WESTACRE RD
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691-3224
Practice Address - Country:US
Practice Address - Phone:916-375-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15187235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist