Basic Information
| Provider Information | |||||||||
| NPI: | 1124258645 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENAGALURI | ||||||||
| FirstName: | JAYA PRAVEEN | ||||||||
| MiddleName: | KUMAR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086255085 | ||||||||
| FaxNumber: | 2086255731 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 W 8TH AVE STE 450E | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094746920 | ||||||||
| FaxNumber: | 5094743014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2009 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | M13830 | ID | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.