Provider Demographics
NPI:1760585921
Name:CLORFENE, JEREMY BYRON (PHD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:BYRON
Last Name:CLORFENE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 LAKEVIEW PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1857
Mailing Address - Country:US
Mailing Address - Phone:847-438-1779
Mailing Address - Fax:
Practice Address - Street 1:565 LAKEVIEW PKWY
Practice Address - Street 2:SUITE 102
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1857
Practice Address - Country:US
Practice Address - Phone:847-438-1779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006349103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL201478Medicare ID - Type Unspecified