Provider Demographics
NPI:1003554197
Name:CARRELL, JACOB CHARLES
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:CHARLES
Last Name:CARRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 N REED LN
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-9585
Mailing Address - Country:US
Mailing Address - Phone:928-322-5493
Mailing Address - Fax:
Practice Address - Street 1:421 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-2724
Practice Address - Country:US
Practice Address - Phone:928-322-9166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies