Provider Demographics
NPI:1801044128
Name:CARRASQUILLO, JENNIFER MIRANDA (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MIRANDA
Last Name:CARRASQUILLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4725 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4603
Mailing Address - Country:US
Mailing Address - Phone:954-414-9750
Mailing Address - Fax:954-414-9751
Practice Address - Street 1:4725 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4603
Practice Address - Country:US
Practice Address - Phone:954-414-9750
Practice Address - Fax:954-414-9751
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1105622084N0400X
FL114802084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFC3341310OtherDEA