Provider Demographics
NPI:1205479789
Name:CARROLL, JERRY MONROE
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:MONROE
Last Name:CARROLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 EVANGELINE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-3151
Mailing Address - Country:US
Mailing Address - Phone:216-512-0995
Mailing Address - Fax:
Practice Address - Street 1:1227 ANSEL RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-3323
Practice Address - Country:US
Practice Address - Phone:216-421-0662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)