Provider Demographics
NPI:1659120483
Name:PECK, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:PECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5649 MESHOPPEN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:PA
Mailing Address - Zip Code:18801-7658
Mailing Address - Country:US
Mailing Address - Phone:607-651-6564
Mailing Address - Fax:
Practice Address - Street 1:6701 W BLONDELL DRIVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623
Practice Address - Country:US
Practice Address - Phone:907-357-9755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0015525225200000X
AK231916225200000X
PATE013514225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant