Provider Demographics
NPI:1679639124
Name:PEACH, JANE A (LCSW)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:A
Last Name:PEACH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 WHITE IBIS LN
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-2097
Mailing Address - Country:US
Mailing Address - Phone:321-848-1971
Mailing Address - Fax:321-773-5479
Practice Address - Street 1:2194 A1A HWY
Practice Address - Street 2:SUITE 204
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4930
Practice Address - Country:US
Practice Address - Phone:321-848-1971
Practice Address - Fax:321-773-5479
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL90791041C0700X
GA0033341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA237098832OtherTAX ID NUMBER