Provider Demographics
NPI:1366448938
Name:CAMPBELL, JACQUELINE M (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 ALEXANDRIA DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3149
Mailing Address - Country:US
Mailing Address - Phone:859-277-3490
Mailing Address - Fax:859-278-5014
Practice Address - Street 1:1701 ALEXANDRIA DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3149
Practice Address - Country:US
Practice Address - Phone:859-277-3490
Practice Address - Fax:859-278-5014
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17047208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64170475Medicaid
C65746Medicare UPIN