Healthcare Provider Details

I. General information

NPI: 1417849670
Provider Name (Legal Business Name): JACQUELENE MCCLOREY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4437 MAIN ST
SHALLOTTE NC
28470-4451
US

IV. Provider business mailing address

860 BERTWOOD RD SW
OCEAN ISLE BEACH NC
28469-1600
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-4449
  • Fax:
Mailing address:
  • Phone: 845-239-8009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-31873
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: