MEDICARE: JILL JOLENE CARBAJAL APRN, FNP-C

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	163W00000X	Registered Nurse	R0127441	OK
2	363LF0000X	Family Nurse Practitioner	225593	OK

General Provider Information

NPI Number	:	1609756139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL JOLENE CARBAJAL APRN, FNP-C

Provider Business Mailing Address
First Line	:	30351 S 650 RD
Second Line	:
City	:	GROVE
State	:	OK
Zip	:	74344-7906
Country	:	US
Telephone Number	:	918-791-5413
Fax Number	:

Provider Business Practice Location Address
First Line	:	1503 HARBOR RD
Second Line	:
City	:	GROVE
State	:	OK
Zip	:	74344-3525
Country	:	US
Telephone Number	:	918-786-3223
Fax Number	:

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

Provider Enumeration Date	:	09/04/2025
Last Update Date	:	09/09/2025

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