MEDICARE: MISS JESSICA L CARROLL PA-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	363LF0000X	Family Nurse Practitioner	25MP00088900	NJ

General Provider Information

NPI Number	:	1942300090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JESSICA L CARROLL PA-C

Provider Business Mailing Address
First Line	:	13421 KELVIN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-1327
Country	:	US
Telephone Number	:	267-474-6792
Fax Number	:

Provider Business Practice Location Address
First Line	:	9501 VENTNOR AVE
Second Line	:
City	:	MARGATE CITY
State	:	NJ
Zip	:	08402-2218
Country	:	US
Telephone Number	:	609-823-6161
Fax Number	:	609-823-3413

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

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/08/2007

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