Provider Demographics
NPI:1548761950
Name:CARZOLI, JAKE WALLACE (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:JAKE
Middle Name:WALLACE
Last Name:CARZOLI
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 PALM BREEZE DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5532
Mailing Address - Country:US
Mailing Address - Phone:334-728-0421
Mailing Address - Fax:
Practice Address - Street 1:11700 MS-57
Practice Address - Street 2:
Practice Address - City:VANCLEAVE
Practice Address - State:MS
Practice Address - Zip Code:39565
Practice Address - Country:US
Practice Address - Phone:228-826-1482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902499363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner