Provider Demographics
NPI:1447561618
Name:CARROLL, JACQUELINE (LCSW-R)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2121
Mailing Address - Country:US
Mailing Address - Phone:631-793-2972
Mailing Address - Fax:
Practice Address - Street 1:31 BEACH AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2121
Practice Address - Country:US
Practice Address - Phone:631-793-2972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-23
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0696921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical