Provider Demographics
NPI:1154139202
Name:GREEN PEACOCK, PLLC
Entity type:Organization
Organization Name:GREEN PEACOCK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:KERI
Authorized Official - Middle Name:
Authorized Official - Last Name:KENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:214-797-8020
Mailing Address - Street 1:2026 BERKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75224-1041
Mailing Address - Country:US
Mailing Address - Phone:214-797-8020
Mailing Address - Fax:469-991-4796
Practice Address - Street 1:729 N BISHOP AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-4340
Practice Address - Country:US
Practice Address - Phone:469-669-3585
Practice Address - Fax:469-991-4796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty