Provider Demographics
NPI:1053131904
Name:CARROLL, JERRETT LEE (APS004717)
Entity type:Individual
Prefix:
First Name:JERRETT
Middle Name:LEE
Last Name:CARROLL
Suffix:
Gender:M
Credentials:APS004717
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1749 IDAHO AVE
Mailing Address - Street 2:
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920
Mailing Address - Country:US
Mailing Address - Phone:330-368-8112
Mailing Address - Fax:
Practice Address - Street 1:658 WALNUT ST SUIT 3
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920
Practice Address - Country:US
Practice Address - Phone:330-932-0157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist