MEDICARE: MRS. JACQUELINE CARROLL L.C.S.W.-R

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	069692	NY

General Provider Information

NPI Number	:	1447561618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JACQUELINE CARROLL L.C.S.W.-R

Provider Business Mailing Address
First Line	:	31 BEACH AVE
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-2121
Country	:	US
Telephone Number	:	631-793-2972
Fax Number	:

Provider Business Practice Location Address
First Line	:	31 BEACH AVE
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-2121
Country	:	US
Telephone Number	:	631-793-2972
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2010
Last Update Date	:	06/23/2010

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