Healthcare Provider Details

I. General information

NPI: 1063071983
Provider Name (Legal Business Name): PATRICIA MARIE CARROLL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 W WASHINGTON AVE
JACKSON MI
49203-1236
US

IV. Provider business mailing address

2424 W WASHINGTON AVE
JACKSON MI
49203-1236
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-4001
  • Fax: 517-787-1286
Mailing address:
  • Phone: 517-205-4001
  • Fax: 517-787-1286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401009331
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: