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General NPI Number Information
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NPI Number | 1568842532
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Entity Type | Individual
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Provider Name | JEREMIAH PECK
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Gender | Male
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Dates
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Enumeration Date | 06/04/2015
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Last Update Date | 08/05/2019
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Provider Practice Location Address
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Address Line | 11105 NE 14TH ST STE 103
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City | VANCOUVER
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State | WA
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Zip | 98684-4309
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Country | US
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Telephone | 360-836-0320
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Fax |
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Provider Business Mailing Address
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Address Line | 11105 NE 14TH ST STE 103
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City | VANCOUVER
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State | WA
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Zip | 98684-4309
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Country | US
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Telephone | 360-836-0320
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Fax | 360-925-2900
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MC60478443
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LH60967738
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License Number State | WA
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