Provider Demographics
NPI:1518582998
Name:GORE, JENNIFER RENEE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RENEE
Last Name:GORE
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 1:1216 W WADE ST
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-2355
Mailing Address - Country:US
Mailing Address - Phone:214-662-4360
Mailing Address - Fax:
Practice Address - Street 1:16386 PINE RIDGE CT
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:TX
Practice Address - Zip Code:75792
Practice Address - Country:US
Practice Address - Phone:214-662-4360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-11
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX85529101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional