Provider Demographics
NPI:1073646253
Name:CAMPBELL, JASON SHANE IV (MHPP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:SHANE
Last Name:CAMPBELL
Suffix:IV
Gender:M
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S. 48TH
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:479-750-8967
Practice Address - Street 1:707 E GREENWOOD
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801
Practice Address - Country:US
Practice Address - Phone:870-777-9800
Practice Address - Fax:870-777-9811
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator