Provider Demographics
NPI:1306849401
Name:CARROLL, JENNIFER L (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9318 STATE ROUTE 14
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241
Mailing Address - Country:US
Mailing Address - Phone:330-626-2710
Mailing Address - Fax:330-626-5978
Practice Address - Street 1:9318 STATE ROUTE 14
Practice Address - Street 2:3RD FLOOR
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-5224
Practice Address - Country:US
Practice Address - Phone:330-626-2710
Practice Address - Fax:330-626-5978
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079394207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2264946Medicaid
OHH38368Medicare UPIN
OH4052132Medicare ID - Type Unspecified