Provider Demographics
NPI:1194851634
Name:CAMPBELL, JESSICA RENA (PCC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENA
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5838 HIGHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-2038
Mailing Address - Country:US
Mailing Address - Phone:513-305-1437
Mailing Address - Fax:
Practice Address - Street 1:7843 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:MADEIRA
Practice Address - State:OH
Practice Address - Zip Code:45243-2608
Practice Address - Country:US
Practice Address - Phone:513-561-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0500044101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional