Provider Demographics
NPI:1174980924
Name:PECKHAM, JULIE
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:PECKHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 MORGAN CIR E
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-3961
Mailing Address - Country:US
Mailing Address - Phone:904-866-2986
Mailing Address - Fax:
Practice Address - Street 1:1134 MORGAN CIR E
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-3961
Practice Address - Country:US
Practice Address - Phone:904-866-2986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities