Healthcare Provider Details

I. General information

NPI: 1831263128
Provider Name (Legal Business Name): JENNIFER M CARROLL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 01/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2667 HIGHWAY 145
SALTILLO MS
38866-9771
US

IV. Provider business mailing address

2667 HIGHWAY 145
SALTILLO MS
38866-9771
US

V. Phone/Fax

Practice location:
  • Phone: 662-869-3042
  • Fax: 662-869-3405
Mailing address:
  • Phone: 662-869-3042
  • Fax: 662-869-3405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1163
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: