Provider Demographics
NPI:1306178918
Name:CAMPBELL, JENNIFER PATRICIA (MA, LPC, CCDP-D)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:PATRICIA
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MA, LPC, CCDP-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9433 THEODOSIA AVE
Mailing Address - Street 2:
Mailing Address - City:OVERLAND
Mailing Address - State:MO
Mailing Address - Zip Code:63114-3715
Mailing Address - Country:US
Mailing Address - Phone:314-566-2290
Mailing Address - Fax:
Practice Address - Street 1:939 GARDENVIEW OFFICE PKWY
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-5917
Practice Address - Country:US
Practice Address - Phone:314-566-2290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-06
Last Update Date:2010-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008010475101Y00000X, 101YP2500X
MO5030101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)