Provider Demographics
NPI:1174168116
Name:PENA, JESSICA MICHELLE (PTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MICHELLE
Last Name:PENA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9301 AXTELLON CT
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-4168
Mailing Address - Country:US
Mailing Address - Phone:512-743-4053
Mailing Address - Fax:
Practice Address - Street 1:4011 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-2491
Practice Address - Country:US
Practice Address - Phone:512-868-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2145800225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant