Provider Demographics
NPI:1255960035
Name:PENA, JACQUELYN MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MICHELLE
Last Name:PENA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS WAY # 653
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-364-1100
Mailing Address - Fax:501-364-4082
Practice Address - Street 1:1 CHILDRENS WAY # 512-8
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-364-4361
Practice Address - Fax:501-364-3404
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-16688208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics