Provider Demographics
NPI:1699433326
Name:PEACOCK, JEREESHA SHAUNTA
Entity type:Individual
Prefix:
First Name:JEREESHA
Middle Name:SHAUNTA
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:KAYENTA
Mailing Address - State:AZ
Mailing Address - Zip Code:86033-0368
Mailing Address - Country:US
Mailing Address - Phone:928-697-4001
Mailing Address - Fax:
Practice Address - Street 1:HWY 160 M.P. 394
Practice Address - Street 2:
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033
Practice Address - Country:US
Practice Address - Phone:928-697-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY36163163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care