Provider Demographics
NPI:1063959724
Name:GILMORE, JACQUELINE LEE (LMSW)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LEE
Last Name:GILMORE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3332
Mailing Address - Country:US
Mailing Address - Phone:607-733-5696
Mailing Address - Fax:
Practice Address - Street 1:1019 E WATER ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-3332
Practice Address - Country:US
Practice Address - Phone:607-799-5696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-19
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072911-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker