Provider Demographics
NPI:1043594013
Name:PEAK, JACK D
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:D
Last Name:PEAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11665 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-6721
Mailing Address - Country:US
Mailing Address - Phone:909-838-2679
Mailing Address - Fax:
Practice Address - Street 1:11665 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-6721
Practice Address - Country:US
Practice Address - Phone:909-838-2679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5824225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5824Medicaid
CA5824Medicare PIN