Provider Demographics
NPI:1144404286
Name:CARROLL, JENNIFER C (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:C
Last Name:CARROLL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 NORTH MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048
Mailing Address - Country:US
Mailing Address - Phone:508-261-2888
Mailing Address - Fax:
Practice Address - Street 1:129 NORTH MAIN ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048
Practice Address - Country:US
Practice Address - Phone:508-261-2888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1024944101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP07270OtherBCBS
MAP2004Medicare PIN