Provider Demographics
NPI:1710547096
Name:CARROLL, JEREMY R (LAC, MAOM)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:R
Last Name:CARROLL
Suffix:
Gender:M
Credentials:LAC, MAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1083 CHAMBERLAIN HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-5546
Mailing Address - Country:US
Mailing Address - Phone:860-922-1073
Mailing Address - Fax:
Practice Address - Street 1:474 MAIN STREET
Practice Address - Street 2:
Practice Address - City:MIDDLEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06455
Practice Address - Country:US
Practice Address - Phone:860-704-9091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000307171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist