Provider Demographics
NPI:1770974016
Name:CARROLL, JILLIAN (PA)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0247
Mailing Address - Country:US
Mailing Address - Phone:601-649-7802
Mailing Address - Fax:601-428-7841
Practice Address - Street 1:1002 JEFFERSON ST
Practice Address - Street 2:SUITE 400
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4306
Practice Address - Country:US
Practice Address - Phone:601-649-7802
Practice Address - Fax:601-428-7841
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical