Basic Information
| Provider Information | |||||||||
| NPI: | 1487053997 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | BOX 100278 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522737832 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | BOX 100278 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522737832 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2014 | ||||||||
| LastUpdateDate: | 08/26/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9108288 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 013517000 | 05 | FL | MEDICAID |