1063100311 NPI number — JAQUELYN PENA OD

Table of content: SCHYLER ANNE MORTON MD (NPI 1023878048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063100311 NPI number — JAQUELYN PENA OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PENA
Provider First Name:
JAQUELYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VEGA
Provider Other First Name:
JACKIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063100311
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2188 STATE HIGHWAY 46 W STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BRAUNFELS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78132-4467
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-302-3357
Provider Business Mailing Address Fax Number:
830-302-3358

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2188 STATE HIGHWAY 46 W STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW BRAUNFELS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78132-4467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-302-3357
Provider Business Practice Location Address Fax Number:
830-302-3358
Provider Enumeration Date:
04/25/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 11109 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)