Provider Demographics
NPI:1104190685
Name:PENA, JAIME ALICIA
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:ALICIA
Last Name:PENA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 NUT TREE RD
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-3508
Mailing Address - Country:US
Mailing Address - Phone:707-564-3505
Mailing Address - Fax:
Practice Address - Street 1:401 NUT TREE RD
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-3508
Practice Address - Country:US
Practice Address - Phone:707-564-3505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111329106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist