Healthcare Provider Details

I. General information

NPI: 1639081581
Provider Name (Legal Business Name): JADE CLARISSE KING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 N ROCKTON AVE
ROCKFORD IL
61103-1942
US

IV. Provider business mailing address

3400 N ROCKTON AVE
ROCKFORD IL
61103-1942
US

V. Phone/Fax

Practice location:
  • Phone: 817-846-0684
  • Fax: 815-673-7362
Mailing address:
  • Phone: 817-846-0684
  • Fax: 815-673-7362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: