Healthcare Provider Details

I. General information

NPI: 1902738743
Provider Name (Legal Business Name): JESSICA RENEE CARROLL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2890 SHELBY 312
CLARENCE MO
63437-3206
US

IV. Provider business mailing address

2890 SHELBY 312
CLARENCE MO
63437-3206
US

V. Phone/Fax

Practice location:
  • Phone: 573-588-4165
  • Fax: 573-588-0034
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2015011600
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: