Provider Demographics
NPI:1205403755
Name:ELMORE, JACQULYN LANAY (PHD)
Entity type:Individual
Prefix:DR
First Name:JACQULYN
Middle Name:LANAY
Last Name:ELMORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 3RD ST
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-1302
Mailing Address - Country:US
Mailing Address - Phone:309-235-5027
Mailing Address - Fax:
Practice Address - Street 1:2200 3RD AVE
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-8840
Practice Address - Country:US
Practice Address - Phone:309-779-2094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health