Provider Demographics
NPI:1497130207
Name:CARRELL, JAQULYN NIKOLE (MED, ATC, LAT, CKTP)
Entity Type:Individual
Prefix:MISS
First Name:JAQULYN
Middle Name:NIKOLE
Last Name:CARRELL
Suffix:
Gender:F
Credentials:MED, ATC, LAT, CKTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 HIGHLAND LAKE WAY
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-7833
Mailing Address - Country:US
Mailing Address - Phone:317-286-8881
Mailing Address - Fax:
Practice Address - Street 1:3910 MONTLAKE BLVD NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:317-286-8881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1 60486324174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist