Provider Demographics
NPI:1528402732
Name:GILMORE, JEANNETTE MARIE (LMFT)
Entity Type:Individual
Prefix:
First Name:JEANNETTE
Middle Name:MARIE
Last Name:GILMORE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:JEANNETTE
Other - Middle Name:MARIE
Other - Last Name:KRAKLOW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 17369
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92177-7369
Mailing Address - Country:US
Mailing Address - Phone:858-882-7872
Mailing Address - Fax:
Practice Address - Street 1:5252 BALBOA AVE STE 800
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6970
Practice Address - Country:US
Practice Address - Phone:858-882-7872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105338106H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program