Provider Demographics
NPI:1972359263
Name:CARROLL, JACQUELYN MARIE
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:MARIE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:MARIE
Other - Last Name:CROWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:423 E PITTSBURGH ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-2659
Mailing Address - Country:US
Mailing Address - Phone:724-309-3910
Mailing Address - Fax:
Practice Address - Street 1:562 SHEARER ST STE 103
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-2746
Practice Address - Country:US
Practice Address - Phone:724-837-1894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP028390363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology