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General NPI Number Information
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NPI Number | 1902738743
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Entity Type | Individual
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Provider Name | JESSICA RENEE CARROLL PTA
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Gender | Female
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Dates
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Enumeration Date | 06/03/2026
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Last Update Date | 06/03/2026
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Provider Practice Location Address
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Address Line | 2890 SHELBY 312
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City | CLARENCE
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State | MO
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Zip | 63437-3206
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Country | US
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Telephone | 573-588-4165
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Fax | 573-588-0034
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Provider Business Mailing Address
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Address Line | 2890 SHELBY 312
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City | CLARENCE
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State | MO
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Zip | 63437-3206
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2015011600
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License Number State | MO
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