Provider Demographics
NPI:1851337224
Name:PEAK, JERLYN DEE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JERLYN
Middle Name:DEE
Last Name:PEAK
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:JERLYN
Other - Middle Name:DEE
Other - Last Name:PADEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:2010 S COOPER CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67207-5819
Mailing Address - Country:US
Mailing Address - Phone:316-652-7874
Mailing Address - Fax:
Practice Address - Street 1:720 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2112
Practice Address - Country:US
Practice Address - Phone:316-322-4580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-000562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer