Provider Demographics
NPI:1154662195
Name:CAMPBELL, JESSICA KINKELAAR (LMP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:KINKELAAR
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:KINKELAAR
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:PO BOX 273
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-0273
Mailing Address - Country:US
Mailing Address - Phone:253-686-4606
Mailing Address - Fax:253-446-6022
Practice Address - Street 1:12815 CANYON RD E STE R
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-5104
Practice Address - Country:US
Practice Address - Phone:253-686-4606
Practice Address - Fax:253-446-6022
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60275438225700000X
WANC10096120376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No376K00000XNursing Service Related ProvidersNurse's Aide