Provider Demographics
NPI:1417340035
Name:PEACOCK, JENNIFER (CPNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2403 N WASHINGTON AVE
Mailing Address - Street 2:235
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-3793
Mailing Address - Country:US
Mailing Address - Phone:214-604-8847
Mailing Address - Fax:
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:214-456-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127440363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics