Healthcare Provider Details

I. General information

NPI: 1205403755
Provider Name (Legal Business Name): JACQULYN LANAY ELMORE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2021
Last Update Date: 06/04/2021
Certification Date: 06/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 3RD AVE
ROCK ISLAND IL
61201-8840
US

IV. Provider business mailing address

1510 3RD ST
EAST MOLINE IL
61244-1302
US

V. Phone/Fax

Practice location:
  • Phone: 309-779-2094
  • Fax:
Mailing address:
  • Phone: 309-235-5027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: