Provider Demographics
NPI:1417469610
Name:CAMPBELL, JACQUELYN A (LPC)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:A
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6909 W RAY RD STE 15
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-1526
Mailing Address - Country:US
Mailing Address - Phone:234-716-6408
Mailing Address - Fax:833-464-3817
Practice Address - Street 1:6909 W RAY RD STE 15
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-1526
Practice Address - Country:US
Practice Address - Phone:234-716-6408
Practice Address - Fax:833-464-3817
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-27
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCP5573-R101Y00000X, 101YM0800X
AZLPC-18602101Y00000X, 101YM0800X, 101YP2500X
OHC.1700534101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health