Provider Demographics
NPI:1306222401
Name:CARROLL, JESSICA ELIZABETH-ROSE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:ELIZABETH-ROSE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 711570
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:HI
Mailing Address - Zip Code:96771-1570
Mailing Address - Country:US
Mailing Address - Phone:808-255-4247
Mailing Address - Fax:
Practice Address - Street 1:11-3059 PLUMERIA STREET
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:HI
Practice Address - Zip Code:96771-1570
Practice Address - Country:US
Practice Address - Phone:808-255-4247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
HIPSY-1813103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health