Healthcare Provider Details

I. General information

NPI: 1699433326
Provider Name (Legal Business Name): JEREESHA SHAUNTA PEACOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2021
Last Update Date: 11/30/2021
Certification Date: 11/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 160 M.P. 394
KAYENTA AZ
86033
US

IV. Provider business mailing address

PO BOX 368
KAYENTA AZ
86033-0368
US

V. Phone/Fax

Practice location:
  • Phone: 928-697-4000
  • Fax:
Mailing address:
  • Phone: 928-697-4001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number36163
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: