Basic Information
| Provider Information | |||||||||
| NPI: | 1497290159 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.S., LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 W CHOCTAW AVE | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182310 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 804 W CHOCTAW AVE | ||||||||
| Address2: | |||||||||
| City: | CHICKASHA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730182310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052220622 | ||||||||
| FaxNumber: | 4052249532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2017 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | 7809 | OK | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.