Provider Demographics
NPI:1124792502
Name:DR JEN CARROLL LLC
Entity type:Organization
Organization Name:DR JEN CARROLL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:CICILIAN
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LAC
Authorized Official - Phone:971-353-7990
Mailing Address - Street 1:14535 WESTLAKE DR STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-7775
Mailing Address - Country:US
Mailing Address - Phone:971-353-7990
Mailing Address - Fax:971-353-7490
Practice Address - Street 1:14535 WESTLAKE DR STE B
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-7775
Practice Address - Country:US
Practice Address - Phone:971-353-7990
Practice Address - Fax:971-353-7490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-09
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service