Healthcare Provider Details

I. General information

NPI: 1982149621
Provider Name (Legal Business Name): JACOB C CARROLL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2017
Last Update Date: 04/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 WAYNE RD
SAVANNAH TN
38372
US

IV. Provider business mailing address

183 UNION AVE
JACKSON TN
38301-6036
US

V. Phone/Fax

Practice location:
  • Phone: 731-926-8000
  • Fax:
Mailing address:
  • Phone: 731-926-0431
  • Fax: 731-541-7075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number22130
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: