Provider Demographics
NPI:1083365381
Name:PECK, JOHN R JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:PECK
Suffix:JR
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 1:4600 KINGSMORE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2124
Mailing Address - Country:US
Mailing Address - Phone:502-422-0714
Mailing Address - Fax:
Practice Address - Street 1:4600 KINGSMORE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40229-2124
Practice Address - Country:US
Practice Address - Phone:502-422-0714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist