Mark Robert Peacock, PTA

Primary specialty

Physical Therapy AssistantTaxonomy code 225200000X

License

9978 Issued in OR

Practice address

6003 SE 136TH Ave
Portland, OR 97236-4567

Phone

(971) 978-1268

NPI assigned

Aug 18, 2021

Last updated

Aug 18, 2021By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1629244800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1629244800000",
    "number": "1982370094",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4560 SE INTERNATIONAL WAY STE 100",
            "city": "MILWAUKIE",
            "state": "OR",
            "postal_code": "972224628"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6003 SE 136TH AVE",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972364567",
            "telephone_number": "971-978-1268"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PEACOCK",
        "first_name": "MARK",
        "middle_name": "ROBERT",
        "credential": "PTA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-08-18",
        "last_updated": "2021-08-18",
        "certification_date": "2021-08-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225200000X",
            "taxonomy_group": "",
            "desc": "Physical Therapy Assistant",
            "state": "OR",
            "license": "9978",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jocelyn Ruby Peacock-Johnson, BS
• Ausa Peacock, LMT
• Brandy Peacock, LMT
• Heather Peacock
• Lisa Peacock, LMFT
• Kathryn Peak, PA-C
• Gerald Peake, PMHNP
• Meredith L. Peake, M.D.
• Michelle Renee Peake
• Peaks to Plains Counseling, LLC (Laurie Kerridge Counseling LLC)

• Physical Therapy Assistant in Portland, OR
• Providers in Portland, OR by specialty
• Physical Therapy Assistant in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 18, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.