Provider Demographics
NPI:1699445213
Name:PEACOCK HARRISON, KIMBERLY JANE (LCSW)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JANE
Last Name:PEACOCK HARRISON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 DUCATUS DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-4067
Mailing Address - Country:US
Mailing Address - Phone:804-550-8414
Mailing Address - Fax:
Practice Address - Street 1:1721 DUCATUS DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-4067
Practice Address - Country:US
Practice Address - Phone:804-550-8414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040040221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical