Provider Demographics
NPI:1326286246
Name:PECK, JENNIFER (MS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PECK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:7513 COURT STREET
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12932-0008
Mailing Address - Country:US
Mailing Address - Phone:518-873-3670
Mailing Address - Fax:518-873-3777
Practice Address - Street 1:7513 COURT STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NY
Practice Address - Zip Code:12932-0008
Practice Address - Country:US
Practice Address - Phone:518-873-3670
Practice Address - Fax:518-873-3777
Is Sole Proprietor?:No
Enumeration Date:2009-01-30
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NYP69193101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02996789Medicaid