Provider Demographics
NPI:1760207419
Name:PIEKSTRA JARA DE LA VEGA, AMANDA CAMILA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:CAMILA
Last Name:PIEKSTRA JARA DE LA VEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 LOCUST ST APT 208
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5797
Mailing Address - Country:US
Mailing Address - Phone:786-352-6063
Mailing Address - Fax:
Practice Address - Street 1:111 SPEEN ST STE 110
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01701-2092
Practice Address - Country:US
Practice Address - Phone:617-250-0226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health