Provider Demographics
NPI:1942300090
Name:CARROLL, JESSICA L (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:L
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13421 KELVIN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-1327
Mailing Address - Country:US
Mailing Address - Phone:267-474-6792
Mailing Address - Fax:
Practice Address - Street 1:9501 VENTNOR AVE
Practice Address - Street 2:
Practice Address - City:MARGATE CITY
Practice Address - State:NJ
Practice Address - Zip Code:08402-2218
Practice Address - Country:US
Practice Address - Phone:609-823-6161
Practice Address - Fax:609-823-3413
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00088900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ065691CY9Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION N
NJP76399Medicare UPIN