Provider Demographics
NPI:1649454679
Name:PENA, JORGE L (CLINICAL PSYCHOLOGIS)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:L
Last Name:PENA
Suffix:
Gender:M
Credentials:CLINICAL PSYCHOLOGIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9225 COLLINS AVENUE
Mailing Address - Street 2:APT. #1411
Mailing Address - City:SURFSIDE
Mailing Address - State:FL
Mailing Address - Zip Code:33154
Mailing Address - Country:US
Mailing Address - Phone:305-442-8692
Mailing Address - Fax:
Practice Address - Street 1:1825 NW 167TH ST
Practice Address - Street 2:SUITE #102
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-4838
Practice Address - Country:US
Practice Address - Phone:305-624-7450
Practice Address - Fax:305-623-7893
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3600302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization