Provider Demographics
NPI:1861607384
Name:PENAFIEL, JACK (OTAL)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:PENAFIEL
Suffix:
Gender:M
Credentials:OTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9860 BALE CT
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-6386
Mailing Address - Country:US
Mailing Address - Phone:443-827-0876
Mailing Address - Fax:
Practice Address - Street 1:7960 SCOTT LEVEL
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208
Practice Address - Country:US
Practice Address - Phone:410-521-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00483225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist