Provider Demographics
NPI:1407915895
Name:CAMPBELL, JACK B (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:B
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5460 BATTLES WHARF DR
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-6962
Mailing Address - Country:US
Mailing Address - Phone:251-990-4910
Mailing Address - Fax:251-929-2123
Practice Address - Street 1:111 REYNOLDS CIR
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-9736
Practice Address - Country:US
Practice Address - Phone:228-872-7120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04327174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist