Provider Demographics
NPI:1356881932
Name:PEACOCK, JEFFERY (OTR/L)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14469-9231
Mailing Address - Country:US
Mailing Address - Phone:585-410-8968
Mailing Address - Fax:
Practice Address - Street 1:131 DRUMLIN CT
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1863
Practice Address - Country:US
Practice Address - Phone:315-332-7315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63021126225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist