Healthcare Provider Details

I. General information

NPI: 1851431258
Provider Name (Legal Business Name): JACQUELINE CARROLL LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 N COLLEGE AVE SUITE 135
INDIANAPOLIS IN
46205-2734
US

IV. Provider business mailing address

3901 N COLLEGE AVE STE 135
INDIANAPOLIS IN
46205-2734
US

V. Phone/Fax

Practice location:
  • Phone: 317-931-8018
  • Fax: 317-931-0943
Mailing address:
  • Phone: 317-789-6108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number3900022A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number39000822A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number39000822A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number39000822A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: