Provider Demographics
NPI:1750429767
Name:GILMORE, JEANNE MARIE
Entity type:Individual
Prefix:
First Name:JEANNE
Middle Name:MARIE
Last Name:GILMORE
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 1:2211 W TONTO RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-3939
Mailing Address - Country:US
Mailing Address - Phone:928-445-4605
Mailing Address - Fax:
Practice Address - Street 1:1453 NO. MAIN ST.
Practice Address - Street 2:
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349-7986
Practice Address - Country:US
Practice Address - Phone:928-627-6985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool