Provider Demographics
NPI:1417255787
Name:CAMPBELL, JEREMY FANE (LAC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:FANE
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 SEACLIFF DR
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-4439
Mailing Address - Country:US
Mailing Address - Phone:831-320-2896
Mailing Address - Fax:
Practice Address - Street 1:621 WATER ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4146
Practice Address - Country:US
Practice Address - Phone:831-320-2896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 14011171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist