Provider Demographics
NPI:1255805990
Name:CARROLL, JAQUELINE DENNISE (CRNP)
Entity type:Individual
Prefix:MS
First Name:JAQUELINE
Middle Name:DENNISE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 MERCER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-3519
Mailing Address - Country:US
Mailing Address - Phone:908-472-6759
Mailing Address - Fax:
Practice Address - Street 1:1526 LOMBARD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146-1625
Practice Address - Country:US
Practice Address - Phone:215-546-5960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP019576363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care