Provider Demographics
NPI:1952167835
Name:PENA FONSECA, ISAIAS
Entity Type:Individual
Prefix:
First Name:ISAIAS
Middle Name:
Last Name:PENA FONSECA
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 1:10240 FULCRUM AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-8178
Mailing Address - Country:US
Mailing Address - Phone:904-422-4966
Mailing Address - Fax:
Practice Address - Street 1:10240 FULCRUM AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-8178
Practice Address - Country:US
Practice Address - Phone:904-422-4966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-325476106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician