Provider Demographics
NPI:1083050785
Name:PEACOCK, JACOB ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ROBERT
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CLIFTON PL APT 1A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-7218
Mailing Address - Country:US
Mailing Address - Phone:616-894-1615
Mailing Address - Fax:
Practice Address - Street 1:102 CLIFTON PL APT 1A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-7218
Practice Address - Country:US
Practice Address - Phone:616-894-1615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293819-12081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine