Provider Demographics
NPI:1396271292
Name:CARROLL, JELISA
Entity type:Individual
Prefix:
First Name:JELISA
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JELISA
Other - Middle Name:ANITA
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2916 GLYNN AVE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4844
Mailing Address - Country:US
Mailing Address - Phone:921-466-5850
Mailing Address - Fax:912-267-7139
Practice Address - Street 1:2916 GLYNN AVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4844
Practice Address - Country:US
Practice Address - Phone:912-466-5850
Practice Address - Fax:912-267-7139
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86289207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine