Provider Demographics
NPI:1568603983
Name:CAMP, JENNIFER HOWARD (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HOWARD
Last Name:CAMP
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:PO BOX 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-512-4808
Mailing Address - Fax:704-512-4838
Practice Address - Street 1:1100 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5814
Practice Address - Country:US
Practice Address - Phone:704-512-4808
Practice Address - Fax:704-512-4838
Is Sole Proprietor?:No
Enumeration Date:2009-03-14
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00515208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1001Medicaid
NC5912867Medicaid
NC2075228Medicare PIN