Provider Demographics
NPI:1922161264
Name:CARROLL, JEAN ANN (RNFNP)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:ANN
Last Name:CARROLL
Suffix:
Gender:F
Credentials:RNFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 PELHAM PL
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-2436
Mailing Address - Country:US
Mailing Address - Phone:510-675-4433
Mailing Address - Fax:
Practice Address - Street 1:3553 WHIPPLE RD
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-1507
Practice Address - Country:US
Practice Address - Phone:510-675-4433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA209277363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP87659Medicare UPIN