Healthcare Provider Details

I. General information

NPI: 1942300090
Provider Name (Legal Business Name): JESSICA L CARROLL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 VENTNOR AVE
MARGATE CITY NJ
08402-2218
US

IV. Provider business mailing address

13421 KELVIN AVE
PHILADELPHIA PA
19116-1327
US

V. Phone/Fax

Practice location:
  • Phone: 609-823-6161
  • Fax: 609-823-3413
Mailing address:
  • Phone: 267-474-6792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25MP00088900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: