Provider Demographics
NPI:1700457140
Name:JELKS, PEGGY ANN
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:ANN
Last Name:JELKS
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 1:1228 HESS ST
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38012-1577
Mailing Address - Country:US
Mailing Address - Phone:731-780-5411
Mailing Address - Fax:
Practice Address - Street 1:1228 HESS ST
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38012-1577
Practice Address - Country:US
Practice Address - Phone:731-780-5411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPC1465101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional