1336513704 NPI number — JENNIFER J. PEACOCK DNP, APRN, NNP-BC

Table of content: JENNIFER J. PEACOCK DNP, APRN, NNP-BC (NPI 1336513704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336513704 NPI number — JENNIFER J. PEACOCK DNP, APRN, NNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEACOCK
Provider First Name:
JENNIFER
Provider Middle Name:
J.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DNP, APRN, NNP-BC
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1336513704
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 N MARIO CAPECCHI DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84113-1103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-662-4100
Provider Business Mailing Address Fax Number:
801-662-4166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2818 W 12875 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84065-6837
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-232-6595
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/22/2015

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: 364SN0000X , with the licence number:  289188-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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