Healthcare Provider Details

I. General information

NPI: 1235114398
Provider Name (Legal Business Name): JAY PEACOCK PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 02/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1367 WASHINGTON AVE SUITE 100
ALBANY NY
12206-1043
US

IV. Provider business mailing address

711 TROY SCHENECTADY RD SUITE 209
LATHAM NY
12110-2442
US

V. Phone/Fax

Practice location:
  • Phone: 518-438-7926
  • Fax: 518-438-8364
Mailing address:
  • Phone: 518-786-1667
  • Fax: 518-786-1954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number021156-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: