Healthcare Provider Details

I. General information

NPI: 1053131904
Provider Name (Legal Business Name): JERRETT LEE CARROLL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 N 6TH AVE
STEUBENVILLE OH
43952-1846
US

IV. Provider business mailing address

PO BOX 464
LISBON OH
44432-0464
US

V. Phone/Fax

Practice location:
  • Phone: 740-283-4946
  • Fax:
Mailing address:
  • Phone: 330-424-1468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: