Provider Demographics
NPI:1154614790
Name:CLORE, JEAN L (PHD)
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:L
Last Name:CLORE
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 1:221 NE GLEN OAK AVE
Mailing Address - Street 2:7 WEST
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61636-0001
Mailing Address - Country:US
Mailing Address - Phone:309-671-8222
Mailing Address - Fax:
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:7 WEST
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0001
Practice Address - Country:US
Practice Address - Phone:309-671-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-16
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008130103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL199968OtherHEALTH ALLIANCE