Provider Demographics
NPI:1104828276
Name:PEAK, JAYNE ELLEN (APN)
Entity Type:Individual
Prefix:MS
First Name:JAYNE
Middle Name:ELLEN
Last Name:PEAK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:MRS
Other - First Name:JAYNE
Other - Middle Name:ELLEN
Other - Last Name:GILMORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:17015 N. 130TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375
Mailing Address - Country:US
Mailing Address - Phone:309-269-3162
Mailing Address - Fax:563-421-3129
Practice Address - Street 1:9900 BREN ROAD EAST
Practice Address - Street 2:MAIL ROUTE MN 008-B213
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343
Practice Address - Country:US
Practice Address - Phone:800-561-0861
Practice Address - Fax:563-421-3129
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7967363LF0000X
IAA059347363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA15939OtherIOWA MIDLANDS CHOICE
IA03262OtherWELLMARK BCBS
IA1583450Medicaid
IA2583450Medicaid
IA2583450Medicaid
IAI15916Medicare PIN