Provider Demographics
NPI:1093396822
Name:CARROLL, JONATHAN ERIC (KLPC, NCPC, NCCE)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ERIC
Last Name:CARROLL
Suffix:
Gender:M
Credentials:KLPC, NCPC, NCCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 SAINT ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-0729
Mailing Address - Country:US
Mailing Address - Phone:270-925-4922
Mailing Address - Fax:
Practice Address - Street 1:318 SAINT ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-0729
Practice Address - Country:US
Practice Address - Phone:270-925-4922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-14
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY148963101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY148963OtherSTATE-ISSUED LICENSE TO PRACTICE