Provider Demographics
NPI:1699019000
Name:CARROLL, JIMMIE LEE
Entity Type:Individual
Prefix:
First Name:JIMMIE
Middle Name:LEE
Last Name:CARROLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 PINEHAVEN STREET EXT
Mailing Address - Street 2:
Mailing Address - City:LAURENS
Mailing Address - State:SC
Mailing Address - Zip Code:29360-2672
Mailing Address - Country:US
Mailing Address - Phone:864-984-6584
Mailing Address - Fax:864-984-6464
Practice Address - Street 1:379 PINEHAVEN STREET EXT
Practice Address - Street 2:
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-2672
Practice Address - Country:US
Practice Address - Phone:864-984-6584
Practice Address - Fax:864-984-6464
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3127224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant