Provider Demographics
NPI:1912026279
Name:CARROLL, JACQUELINE ANN (ADN)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:ANN
Last Name:CARROLL
Suffix:
Gender:F
Credentials:ADN
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:ANN
Other - Last Name:BUCHNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ADN
Mailing Address - Street 1:2144 KING ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-4245
Mailing Address - Country:US
Mailing Address - Phone:608-790-6508
Mailing Address - Fax:
Practice Address - Street 1:1407 SAINT ANDREW ST
Practice Address - Street 2:STE 100
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-3301
Practice Address - Country:US
Practice Address - Phone:608-785-6215
Practice Address - Fax:608-785-6315
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health