Provider Demographics
NPI:1114699220
Name:CAMPBELL, JENA (LAB DIRECTOR)
Entity Type:Individual
Prefix:
First Name:JENA
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LAB DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4030 WAKE FOREST RD STE 349
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-0010
Mailing Address - Country:US
Mailing Address - Phone:210-251-9938
Mailing Address - Fax:
Practice Address - Street 1:4030 WAKE FOREST RD STE 349
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-0010
Practice Address - Country:US
Practice Address - Phone:210-251-9938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC214224163W00000X
NC34D2236830291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty