Provider Demographics
NPI:1407995319
Name:CARROLL, JEFF (PHD)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4918
Mailing Address - Country:US
Mailing Address - Phone:616-392-5141
Mailing Address - Fax:
Practice Address - Street 1:854 WASHINGTON AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7144
Practice Address - Country:US
Practice Address - Phone:616-355-3926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006647103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical