Provider Demographics
NPI:1982149621
Name:CARROLL, JACOB C (CRNA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:C
Last Name:CARROLL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-6036
Mailing Address - Country:US
Mailing Address - Phone:731-926-0431
Mailing Address - Fax:731-541-7075
Practice Address - Street 1:935 WAYNE RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372
Practice Address - Country:US
Practice Address - Phone:731-926-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22130367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered