Provider Demographics
NPI:1417655606
Name:PELOQUIN, JENNIFER JEAN
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JEAN
Last Name:PELOQUIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 E AUGUSTA AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:KS
Mailing Address - Zip Code:67010-2100
Mailing Address - Country:US
Mailing Address - Phone:316-775-5491
Mailing Address - Fax:
Practice Address - Street 1:524 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2024
Practice Address - Country:US
Practice Address - Phone:316-321-6036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12437104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker