Healthcare Provider Details

I. General information

NPI: 1639199797
Provider Name (Legal Business Name): JENNIFER CARROLL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 LAKE AVE
ROCHESTER NY
14608-1017
US

IV. Provider business mailing address

480 GENESEE ST
ROCHESTER NY
14611-3634
US

V. Phone/Fax

Practice location:
  • Phone: 585-254-6480
  • Fax: 585-254-1092
Mailing address:
  • Phone: 585-254-6480
  • Fax: 585-254-1092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number214505
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: