Provider Demographics
NPI:1891224721
Name:CARROLL, JENNIE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14934 RUSSET BEND LN
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-8527
Mailing Address - Country:US
Mailing Address - Phone:281-610-4430
Mailing Address - Fax:
Practice Address - Street 1:11307 FM 1960 RD W STE 130
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-4918
Practice Address - Country:US
Practice Address - Phone:281-469-9955
Practice Address - Fax:832-912-4083
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133656363LP0200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty