Provider Demographics
NPI:1588119887
Name:PEACOCK, JAMES E (CSAC, ICS)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:E
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:CSAC, ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36745 AIKEN RD
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54814-4579
Mailing Address - Country:US
Mailing Address - Phone:715-779-3707
Mailing Address - Fax:715-779-3362
Practice Address - Street 1:36745 AIKEN RD
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:WI
Practice Address - Zip Code:54814-4579
Practice Address - Country:US
Practice Address - Phone:715-779-3707
Practice Address - Fax:715-779-3362
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14968-132101YM0800X
WI14968132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100059919Medicaid