Provider Demographics
NPI:1407097066
Name:CARROLL, NICOLE JON (MSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:JON
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1457
Mailing Address - Country:US
Mailing Address - Phone:971-235-0388
Mailing Address - Fax:
Practice Address - Street 1:3310 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1457
Practice Address - Country:US
Practice Address - Phone:971-235-0388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL26581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical