Provider Demographics
NPI:1326613787
Name:CALLAWAY-CAMPBELL, JACKIE (DT)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:CALLAWAY-CAMPBELL
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 7TH ST SE APT 103
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-1272
Mailing Address - Country:US
Mailing Address - Phone:302-598-3863
Mailing Address - Fax:
Practice Address - Street 1:405 BABCOCK BLVD E STE 130
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:MN
Practice Address - Zip Code:55328-9144
Practice Address - Country:US
Practice Address - Phone:763-276-1410
Practice Address - Fax:763-276-1411
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT136125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist