Provider Demographics
NPI:1235683137
Name:CAMPBELL, JENISE (JD, MSW)
Entity Type:Individual
Prefix:
First Name:JENISE
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:JD, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 POST OFFICE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALEM
Mailing Address - State:NY
Mailing Address - Zip Code:10590-1104
Mailing Address - Country:US
Mailing Address - Phone:310-994-5024
Mailing Address - Fax:
Practice Address - Street 1:168 POST OFFICE RD
Practice Address - Street 2:
Practice Address - City:SOUTH SALEM
Practice Address - State:NY
Practice Address - Zip Code:10590-1104
Practice Address - Country:US
Practice Address - Phone:310-994-5024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9302104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker